Provider Demographics
NPI:1447818422
Name:F.H. RUSSOMANNO JR., D.D.S.. P.A.,
Entity type:Organization
Organization Name:F.H. RUSSOMANNO JR., D.D.S.. P.A.,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-731-6464
Mailing Address - Street 1:1077 HELMO AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5518
Mailing Address - Country:US
Mailing Address - Phone:651-731-6464
Mailing Address - Fax:
Practice Address - Street 1:1077 HELMO AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-5518
Practice Address - Country:US
Practice Address - Phone:651-731-6464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-04
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental