Provider Demographics
NPI:1477668028
Name:DOMINGO, ERNANI S (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERNANI
Middle Name:S
Last Name:DOMINGO
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 1:33 BAY ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104
Mailing Address - Country:US
Mailing Address - Phone:603-624-1342
Mailing Address - Fax:
Practice Address - Street 1:33 BAY ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104
Practice Address - Country:US
Practice Address - Phone:603-624-1342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3143122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30303367Medicaid