Provider Demographics
NPI:1033430590
Name:CARRUTH, DANA MICHELLE (LAC)
Entity Type:Individual
Prefix:MS
First Name:DANA
Middle Name:MICHELLE
Last Name:CARRUTH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13053
Mailing Address - Country:US
Mailing Address - Phone:607-844-3304
Mailing Address - Fax:
Practice Address - Street 1:87 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:NY
Practice Address - Zip Code:13053
Practice Address - Country:US
Practice Address - Phone:607-844-3304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25 004375171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist