Healthcare Provider Details

I. General information

NPI: 1275925703
Provider Name (Legal Business Name): DOMINIQUE DENT LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 COLRAIN ST SW STE 2
GRAND RAPIDS MI
49548-1057
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-988-1479
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801096027
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: