Provider Demographics
NPI:1922144617
Name:RUSSO, WALTER FRANK (DMD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:FRANK
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 1:85 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-1950
Mailing Address - Country:US
Mailing Address - Phone:203-878-1445
Mailing Address - Fax:203-876-8305
Practice Address - Street 1:85 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-1950
Practice Address - Country:US
Practice Address - Phone:203-878-1445
Practice Address - Fax:203-876-8305
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6412122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist