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General NPI Number Information
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NPI Number | 1982803078
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Entity Type | Organization
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Legal Business Name | MICHAEL G. DOMINOV, DDS PC
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Dates
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Enumeration Date | 07/17/2007
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Last Update Date | 07/17/2007
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Provider Practice Location Address
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Address Line | 17 FRANKLIN ST
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City | LEE
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State | MA
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Zip | 01238-1629
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Country | US
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Telephone | 413-243-0098
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Fax | 413-243-2663
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Provider Business Mailing Address
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Address Line | 17 FRANKLIN ST
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City | LEE
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State | MA
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Zip | 01238-1629
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Country | US
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Telephone | 413-243-0098
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Fax | 413-243-2663
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL GEORGE DOMINOV
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Credential | DDS
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Telephone | 413-243-0098
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 16758
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License Number State | MA
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