Provider Demographics
NPI:1427172071
Name:DERUSSY, DANIEL MAXWELL (DDS)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:MAXWELL
Last Name:DERUSSY
Suffix:
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 1:6700 CROSSWINDS DR NO
Mailing Address - Street 2:STE 400C
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710
Mailing Address - Country:US
Mailing Address - Phone:727-345-8595
Mailing Address - Fax:727-345-0496
Practice Address - Street 1:6700 CROSSWINDS DRIVE NORTH
Practice Address - Street 2:STE 400C
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710
Practice Address - Country:US
Practice Address - Phone:727-345-8595
Practice Address - Fax:727-345-0496
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFLORIDA 045551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice