Provider Demographics
NPI:1063553774
Name:RUSSO, RICHARD G (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
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 1:2500 21ST ST NW APT 79
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-1275
Mailing Address - Country:US
Mailing Address - Phone:863-299-7748
Mailing Address - Fax:
Practice Address - Street 1:832 W CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-1809
Practice Address - Country:US
Practice Address - Phone:407-836-2616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN108291223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL072262600Medicaid
FLDN10829OtherSTATE LICENSE
FLDN10829OtherSTATE LICENSE