Healthcare Provider Details

I. General information

NPI: 1982803078
Provider Name (Legal Business Name): MICHAEL G. DOMINOV, DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 FRANKLIN ST
LEE MA
01238-1629
US

IV. Provider business mailing address

17 FRANKLIN ST
LEE MA
01238-1629
US

V. Phone/Fax

Practice location:
  • Phone: 413-243-0098
  • Fax: 413-243-2663
Mailing address:
  • Phone: 413-243-0098
  • Fax: 413-243-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number16758
License Number StateMA

VIII. Authorized Official

Name: DR. MICHAEL GEORGE DOMINOV
Title or Position: PRESIDENT
Credential: DDS
Phone: 413-243-0098