Provider Demographics
NPI:1396994935
Name:RUSSO, JANE A (DMD)
Entity type:Individual
Prefix:DR
First Name:JANE
Middle Name:A
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 POST RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6016
Mailing Address - Country:US
Mailing Address - Phone:203-256-8073
Mailing Address - Fax:203-256-8378
Practice Address - Street 1:1305 POST RD
Practice Address - Street 2:SUITE 104
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6016
Practice Address - Country:US
Practice Address - Phone:203-256-8073
Practice Address - Fax:203-256-8378
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007020122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist