Provider Demographics
NPI:1457565707
Name:RUSSO, TONI LYNN (DMD)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:LYNN
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 1:233 HAZARD AVE
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4647
Mailing Address - Country:US
Mailing Address - Phone:860-749-6622
Mailing Address - Fax:
Practice Address - Street 1:233 HAZARD AVE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4647
Practice Address - Country:US
Practice Address - Phone:860-749-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101051223P0221X
MADN18552541223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry