Provider Demographics
NPI:1881628501
Name:RUSSO, CAMILLE JOSEPH III (DDS)
Entity type:Individual
Prefix:DR
First Name:CAMILLE
Middle Name:JOSEPH
Last Name:RUSSO
Suffix:III
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 1:1504 E HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-4766
Mailing Address - Country:US
Mailing Address - Phone:225-644-5311
Mailing Address - Fax:225-644-5312
Practice Address - Street 1:1504 E HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4766
Practice Address - Country:US
Practice Address - Phone:225-644-5311
Practice Address - Fax:225-644-5312
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA34671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice