Provider Demographics
NPI:1821206558
Name:SCHENCK, EMILIE RUSSO (DDS)
Entity Type:Individual
Prefix:DR
First Name:EMILIE
Middle Name:RUSSO
Last Name:SCHENCK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 ST. ANN DR.
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471
Mailing Address - Country:US
Mailing Address - Phone:985-626-4807
Mailing Address - Fax:985-626-3198
Practice Address - Street 1:215 ST. ANN DR.
Practice Address - Street 2:SUITE 5
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471
Practice Address - Country:US
Practice Address - Phone:985-626-4807
Practice Address - Fax:985-626-3198
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA56601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09433564Medicaid
LA1856606Medicaid