Provider Demographics
NPI:1003927302
Name:RUSSO, MELANIE E (DMD)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:E
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 BLOOMFIELD AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-1630
Mailing Address - Country:US
Mailing Address - Phone:973-239-3311
Mailing Address - Fax:973-239-3312
Practice Address - Street 1:685 BLOOMFIELD AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-1630
Practice Address - Country:US
Practice Address - Phone:973-239-3311
Practice Address - Fax:973-239-3312
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD101781101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice