Provider Demographics
NPI:1245205038
Name:GREENFIELD, DOMINIC IAN (LAT)
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:IAN
Last Name:GREENFIELD
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 S 52ND ST
Mailing Address - Street 2:
Mailing Address - City:WEST MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-5412
Mailing Address - Country:US
Mailing Address - Phone:262-951-5908
Mailing Address - Fax:
Practice Address - Street 1:2345 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2211
Practice Address - Country:US
Practice Address - Phone:262-658-7305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI531-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer