Provider Demographics
NPI:1942425137
Name:LOUIS J RUSSO JR JONATHAN L NICOZISIS DMD MS PA
Entity Type:Organization
Organization Name:LOUIS J RUSSO JR JONATHAN L NICOZISIS DMD MS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:NICOZISIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:609-924-3271
Mailing Address - Street 1:601 EWING ST
Mailing Address - Street 2:B 12
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-2757
Mailing Address - Country:US
Mailing Address - Phone:609-924-3271
Mailing Address - Fax:
Practice Address - Street 1:601 EWING ST
Practice Address - Street 2:B 12
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-2757
Practice Address - Country:US
Practice Address - Phone:609-924-3271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI 207751223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty