Provider Demographics
NPI:1194250019
Name:PETER A. RUSSO, DDS, INC.
Entity type:Organization
Organization Name:PETER A. RUSSO, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-842-2515
Mailing Address - Street 1:18800 MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1707
Mailing Address - Country:US
Mailing Address - Phone:714-842-2515
Mailing Address - Fax:714-847-7075
Practice Address - Street 1:18800 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1707
Practice Address - Country:US
Practice Address - Phone:714-842-2515
Practice Address - Fax:714-847-7075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty