Provider Demographics
NPI:1992914063
Name:MICHAEL RUSSO DDS SUSAN E SCHARLOCK DDS
Entity type:Organization
Organization Name:MICHAEL RUSSO DDS SUSAN E SCHARLOCK DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:610-696-1025
Mailing Address - Street 1:1039 GENERAL LAFAYETTE BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-8084
Mailing Address - Country:US
Mailing Address - Phone:610-793-0525
Mailing Address - Fax:
Practice Address - Street 1:2 CIRCLE AVE
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19382-4808
Practice Address - Country:US
Practice Address - Phone:610-696-1025
Practice Address - Fax:610-696-1058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024419L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty