Provider Demographics
NPI:1588199731
Name:DANDENAULT, IAN (LAC , RAC , MSTOM)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:DANDENAULT
Suffix:
Gender:M
Credentials:LAC , RAC , MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 DIVISION ST N
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3953
Mailing Address - Country:US
Mailing Address - Phone:616-308-4583
Mailing Address - Fax:
Practice Address - Street 1:156 DIVISION ST N
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3953
Practice Address - Country:US
Practice Address - Phone:616-308-4583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5401000218171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist