Provider Demographics
NPI:1225140494
Name:DAMICO, DOMENIC (DMD)
Entity Type:Individual
Prefix:MR
First Name:DOMENIC
Middle Name:
Last Name:DAMICO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02474
Mailing Address - Country:US
Mailing Address - Phone:617-926-1801
Mailing Address - Fax:617-923-9618
Practice Address - Street 1:359 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02474
Practice Address - Country:US
Practice Address - Phone:617-926-1801
Practice Address - Fax:617-923-9618
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA177101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice