Provider Demographics
NPI:1699809202
Name:RUSSO, STEPHEN P (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:P
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 E. WASHINGTON ST
Mailing Address - Street 2:SUITE 1125
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602
Mailing Address - Country:US
Mailing Address - Phone:312-641-2572
Mailing Address - Fax:312-641-6621
Practice Address - Street 1:25 E. WASHINGTON ST
Practice Address - Street 2:SUITE 1125
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602
Practice Address - Country:US
Practice Address - Phone:312-641-2572
Practice Address - Fax:312-641-6621
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0264571223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics