Provider Demographics
NPI:1881206712
Name:CARUSO, EMILY NICOLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:NICOLE
Last Name:CARUSO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:EMILY
Other - Middle Name:NICOLE
Other - Last Name:CARUSO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:43 SHADDEN SPGS
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4195
Mailing Address - Country:US
Mailing Address - Phone:904-361-8641
Mailing Address - Fax:
Practice Address - Street 1:94223 4TH ST
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-7756
Practice Address - Country:US
Practice Address - Phone:541-837-1682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013477A122300000X
ORD1188771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist