Provider Demographics
NPI:1295803443
Name:RUSSO, CHARLES D (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
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 1:2801 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-5057
Mailing Address - Country:US
Mailing Address - Phone:954-752-1045
Mailing Address - Fax:954-344-9651
Practice Address - Street 1:2801 N UNIVERSITY DR
Practice Address - Street 2:SUITE 102
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-5057
Practice Address - Country:US
Practice Address - Phone:954-752-1045
Practice Address - Fax:954-344-9651
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0083381223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL66171Medicare ID - Type Unspecified
FLT97430Medicare UPIN