Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 039175 | NY |
NPI | 1205812765 |
---|---|
Provider Name | Dr. Nicolas Henry Russo |
First Address | Beaufort, SC 29902-6122 |
Second Address | Beaufort, SC 29902-6122 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/12/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000OTH | (02) |