Organization
RUSSO DENTAL LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. NICHOLAS VITO RUSSO D.D.S. (OWNER)
(262) 894-1071
Entity
Organization
Contact information
Practice address
12690 W NORTH AVE, BROOKFIELD, WI 53005-4636
(262) 784-3740
(262) 784-3840
Mailing address
12690 W NORTH AVE, BROOKFIELD, WI 53005-4636
(262) 784-3740
(262) 784-3840
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
1000994-15
WI
Other
Enumeration date
01/08/2015
Last updated
01/08/2015
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