Provider Demographics
NPI:1992475438
Name:RUSSELL, EMILIE CARON (DMD)
Entity type:Individual
Prefix:
First Name:EMILIE
Middle Name:CARON
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PARK GATE DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-3033
Mailing Address - Country:US
Mailing Address - Phone:662-840-1535
Mailing Address - Fax:662-844-3823
Practice Address - Street 1:101 PARK GATE DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-3033
Practice Address - Country:US
Practice Address - Phone:662-840-1535
Practice Address - Fax:662-844-3823
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4201-211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice