Provider Demographics
NPI:1134786726
Name:RUSSO, LISA DAWN
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DAWN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2855 E BLACKHAWK CT
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-1003
Mailing Address - Country:US
Mailing Address - Phone:480-302-1806
Mailing Address - Fax:
Practice Address - Street 1:2855 E BLACKHAWK CT
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298-1003
Practice Address - Country:US
Practice Address - Phone:480-302-1806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH06294124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist