Provider Demographics
NPI:1093735524
Name:GANIM, DIMITRI GEORGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIMITRI
Middle Name:GEORGE
Last Name:GANIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:878 NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02861-2642
Mailing Address - Country:US
Mailing Address - Phone:401-725-6140
Mailing Address - Fax:401-726-8045
Practice Address - Street 1:878 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02861-2642
Practice Address - Country:US
Practice Address - Phone:401-725-6140
Practice Address - Fax:401-726-8045
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI16611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice