| NPI | 1538557848 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | NICHOLAS VITO RUSSO Owner 262-894-1071 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WI 1000994-15) |
| Enumeration Date | 2015-01-08 |
| Last Update Date | 2015-01-08 |