Healthcare Provider Details

I. General information

NPI: 1184170722
Provider Name (Legal Business Name): MR. DOMINIQUE MARROW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LANDSTUHL DENTAC CMR 402
APO AE
09180
US

IV. Provider business mailing address

LANDSTUHL DENTAC CMR 402
APO AE
09180
US

V. Phone/Fax

Practice location:
  • Phone: 4963719464430
  • Fax:
Mailing address:
  • Phone: 4963719464430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: