Provider Demographics
NPI:1720697808
Name:RUSSOMANNO KEANE DDS PA
Entity Type:Organization
Organization Name:RUSSOMANNO KEANE DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-307-4966
Mailing Address - Street 1:8910 PENN AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-2025
Mailing Address - Country:US
Mailing Address - Phone:952-881-0504
Mailing Address - Fax:
Practice Address - Street 1:1975 11TH AVE E
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-5148
Practice Address - Country:US
Practice Address - Phone:651-770-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty