Healthcare Provider Details

I. General information

NPI: 1265838304
Provider Name (Legal Business Name): DOMINIC GENTILE MS, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2014
Last Update Date: 12/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115-6110
US

IV. Provider business mailing address

145 GRANT AVE APARTMENT 2
MEDFORD MA
02155-4041
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-5500
  • Fax:
Mailing address:
  • Phone: 508-736-7314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN267728
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: