Provider Demographics
NPI:1811041726
Name:ILLUZZI-RUSSO, ANGELA MICHELLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:MICHELLE
Last Name:ILLUZZI-RUSSO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LONE PINE LN
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-6119
Mailing Address - Country:US
Mailing Address - Phone:917-502-0030
Mailing Address - Fax:
Practice Address - Street 1:190 PARK AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1000
Practice Address - Country:US
Practice Address - Phone:207-874-1028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0528091223S0112X
NJ22DI023471001223S0112X
MEDEN48361223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty