Individual
THOMAS DAVID RUSSO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.M.D.
Contact information
Practice address
63 SHORE RD STE 13, WINCHESTER, MA 01890-2828
(781) 721-4700
(781) 729-0798
Mailing address
63 SHORE RD STE 13, WINCHESTER, MA 01890-2828
(781) 721-4700
(781) 729-0798
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
15641
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0263001
—
MA
01
—
661706
UNITED CONCORDIA
MA
01
—
RU10679
BLUE CROSS BLUE SHIELD
MA
Enumeration date
06/01/2007
Last updated
07/09/2007
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