Healthcare Provider Details

I. General information

NPI: 1871031492
Provider Name (Legal Business Name): FRANKLIN DEDOMINICIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1952 WHITNEY AVE STE 8
HAMDEN CT
06517-1209
US

IV. Provider business mailing address

1952 WHITNEY AVE STE 8
HAMDEN CT
06517-1209
US

V. Phone/Fax

Practice location:
  • Phone: 203-848-1803
  • Fax: 203-848-1777
Mailing address:
  • Phone: 203-848-1803
  • Fax: 203-848-1777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number23.003773
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: