Provider Demographics
NPI:1780472308
Name:RUSSO, JONATHAN P (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:P
Last Name:RUSSO
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 MAYMONT DR
Mailing Address - Street 2:
Mailing Address - City:CRAMERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28032-1611
Mailing Address - Country:US
Mailing Address - Phone:704-840-6342
Mailing Address - Fax:
Practice Address - Street 1:11110 FORT ST STE 106
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-2183
Practice Address - Country:US
Practice Address - Phone:402-492-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program