Provider Demographics
NPI:1174695613
Name:RUSSO, DENNIS AHLERT JR (DC)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:AHLERT
Last Name:RUSSO
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:RUSTY
Other - Middle Name:
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:4417 LORINO ST STE 104
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-6800
Mailing Address - Country:US
Mailing Address - Phone:504-407-0896
Mailing Address - Fax:504-582-9710
Practice Address - Street 1:4417 LORINO ST STE 104
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-6800
Practice Address - Country:US
Practice Address - Phone:504-407-0896
Practice Address - Fax:504-582-9710
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1421111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor