Provider Demographics
NPI:1689875114
Name:RUSSO, LEONARD ROSS (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:ROSS
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 LOS COYOTES DGL
Mailing Address - Street 2:#102
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-3936
Mailing Address - Country:US
Mailing Address - Phone:562-421-8858
Mailing Address - Fax:562-627-0149
Practice Address - Street 1:3320 LOS COYOTES DGL
Practice Address - Street 2:#102
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-3936
Practice Address - Country:US
Practice Address - Phone:562-421-8858
Practice Address - Fax:562-627-0149
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18624122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB1862401Medicaid