Provider Demographics
NPI:1720583222
Name:WISCOVITCH RUSSO, ALEJANDRO JAVIER (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALEJANDRO
Middle Name:JAVIER
Last Name:WISCOVITCH 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 1:7 VINEYARD LN APT 111
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-7066
Mailing Address - Country:US
Mailing Address - Phone:787-643-5041
Mailing Address - Fax:
Practice Address - Street 1:ASPEN DENTAL
Practice Address - Street 2:1159 ULSTER AVE
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401
Practice Address - Country:US
Practice Address - Phone:845-336-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0616931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program