Provider Demographics
NPI:1609903939
Name:DECARLO, RUSSELL ANTHONY (DDS)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ANTHONY
Last Name:DECARLO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:RUSSELL
Other - Middle Name:A
Other - Last Name:DECARLO DDS PC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4601D PINECREST OFFICE PARK DRIVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-1442
Mailing Address - Country:US
Mailing Address - Phone:703-642-1400
Mailing Address - Fax:703-642-5759
Practice Address - Street 1:4601D PINECREST OFFICE PARK DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22312-1442
Practice Address - Country:US
Practice Address - Phone:703-642-1400
Practice Address - Fax:703-642-5759
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3829122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist