Healthcare Provider Details

I. General information

NPI: 1205037140
Provider Name (Legal Business Name): INGRID MARY ELIZABETH DE BAINTNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEETING HOUSE HILL RD
DOVER MA
02030-2135
US

IV. Provider business mailing address

1 MEETING HOUSE HILL RD
DOVER MA
02030-2135
US

V. Phone/Fax

Practice location:
  • Phone: 508-785-2455
  • Fax:
Mailing address:
  • Phone: 508-785-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number46004
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: