Healthcare Provider Details

I. General information

NPI: 1154026508
Provider Name (Legal Business Name): JAMIE ALLISON DIDOMENICO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 BELMONT AVE
YOUNGSTOWN OH
44504-1006
US

IV. Provider business mailing address

117 OAK TREE DR
CANFIELD OH
44406-9296
US

V. Phone/Fax

Practice location:
  • Phone: 330-480-2994
  • Fax:
Mailing address:
  • Phone: 330-565-1948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number004585
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: