Provider Demographics
NPI:1477134807
Name:BALDWIN, DOMINIQUE ARIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:ARIEL
Last Name:BALDWIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 PEGASUS BAY DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-3835
Mailing Address - Country:US
Mailing Address - Phone:336-567-5969
Mailing Address - Fax:
Practice Address - Street 1:80 AUTUMN FERN TRL
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-5155
Practice Address - Country:US
Practice Address - Phone:910-814-4191
Practice Address - Fax:910-814-4198
Is Sole Proprietor?:No
Enumeration Date:2021-04-17
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC122811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program