Provider Demographics
NPI:1265838304
Name:GENTILE, DOMINIC (MS, CRNA)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:GENTILE
Suffix:
Gender:M
Credentials:MS, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 GRANT AVE
Mailing Address - Street 2:APARTMENT 2
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4041
Mailing Address - Country:US
Mailing Address - Phone:508-736-7314
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2014-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN267728367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered