Provider Demographics
NPI:1205149275
Name:RUSSO, JUSTIN (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 ED DR STE 120
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2393
Mailing Address - Country:US
Mailing Address - Phone:919-890-5147
Mailing Address - Fax:919-890-5953
Practice Address - Street 1:3811 ED DR STE 120
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-2393
Practice Address - Country:US
Practice Address - Phone:919-890-5147
Practice Address - Fax:919-890-5953
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0393421223G0001X
NC90611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice