Provider Demographics
NPI:1861682460
Name:GUS S. RUSSO DDS PC
Entity Type:Organization
Organization Name:GUS S. RUSSO DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUS
Authorized Official - Middle Name:S
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:215-757-0864
Mailing Address - Street 1:310 MIDDLETOWN BLVD
Mailing Address - Street 2:THE COURTYARD AT OXFORD VALLEY STE 202
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-3203
Mailing Address - Country:US
Mailing Address - Phone:215-757-0864
Mailing Address - Fax:215-757-8090
Practice Address - Street 1:310 MIDDLETOWN BLVD
Practice Address - Street 2:THE COURTYARD AT OXFORD VALLEY STE 202
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-3203
Practice Address - Country:US
Practice Address - Phone:215-757-0864
Practice Address - Fax:215-757-8090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO19052L1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty