Provider Demographics
NPI:1730163320
Name:COLARUSSO, CARMINE (DMD)
Entity type:Individual
Prefix:DR
First Name:CARMINE
Middle Name:
Last Name:COLARUSSO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 JUNGLE RD
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-5208
Mailing Address - Country:US
Mailing Address - Phone:978-534-8300
Mailing Address - Fax:978-840-8508
Practice Address - Street 1:2 JUNGLE RD
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453
Practice Address - Country:US
Practice Address - Phone:978-534-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19642174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAU75314Medicare UPIN