Provider Demographics
NPI:1164941340
Name:DAVIS, DOMINIQUE K
Entity Type:Individual
Prefix:MR
First Name:DOMINIQUE
Middle Name:K
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:BRADDOCK
Mailing Address - State:PA
Mailing Address - Zip Code:15104-1647
Mailing Address - Country:US
Mailing Address - Phone:412-378-8630
Mailing Address - Fax:
Practice Address - Street 1:700 PARKER AVE APT 9
Practice Address - Street 2:
Practice Address - City:BRADDOCK
Practice Address - State:PA
Practice Address - Zip Code:15104
Practice Address - Country:US
Practice Address - Phone:412-378-8630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier