Angela Michelle Illuzzi-Russo, DDS

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

DEN4836 Issued in ME

Practice address

190 Park Ave
Portland, ME 04102-1000

Phone

(207) 874-1028

NPI assigned

Jan 22, 2007

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Jan 1, 2025 through Jan 1, 2027

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Interoperability endpoints

• Direct secure messaging: ailluzzirusso189797@ahs.direct-ci.com
• Direct secure messaging: ailluzzirusso346317@direct.mmc.mainehealth.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Southern Maine Oral and Maxillofacial Surgery PA

  • Oral and Maxillofacial Surgery (Dentist)
  • South Portland, ME
  • NPI 1831256338
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169424000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1612396800000",
    "number": "1811041726",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10 LONE PINE LN",
            "city": "YARMOUTH",
            "state": "ME",
            "postal_code": "040966119",
            "telephone_number": "917-502-0030"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "190 PARK AVE",
            "city": "PORTLAND",
            "state": "ME",
            "postal_code": "041021000",
            "telephone_number": "207-874-1028"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ILLUZZI-RUSSO",
        "first_name": "ANGELA",
        "middle_name": "MICHELLE",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-01-22",
        "last_updated": "2021-02-04",
        "certification_date": "2021-02-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NY",
            "license": "052809",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NJ",
            "license": "22DI02347100",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "ME",
            "license": "DEN4836",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Sarah Ibrahim, DO
• Peter A Igneri, PA-C, MMSC
• Kayli Igoe
• Vanessa Marie Ilias, AGACNP-BC, APRN
• John Joseph Illuminati, DDS
• Kara Lyn Im, LCSW
• Ladan S Iman, LMSW-CC
• Paige Elizabeth Imperato
• Krista Imre, ND
• Inclusive Minds Foundation Co.

• Oral and Maxillofacial Surgery (Dentist) in Portland, ME
• Providers in Portland, ME by specialty
• Oral and Maxillofacial Surgery (Dentist) in Maine

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 4, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.