Provider Demographics
NPI:1477881290
Name:DOMENICK COLETTI DDS, MD, PC
Entity Type:Organization
Organization Name:DOMENICK COLETTI DDS, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOMENICK
Authorized Official - Middle Name:
Authorized Official - Last Name:COLETTI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD, FACS
Authorized Official - Phone:410-997-1010
Mailing Address - Street 1:10710 CHARTER DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3128
Mailing Address - Country:US
Mailing Address - Phone:410-997-1010
Mailing Address - Fax:410-997-0807
Practice Address - Street 1:10710 CHARTER DR
Practice Address - Street 2:SUITE 330
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3128
Practice Address - Country:US
Practice Address - Phone:410-997-1010
Practice Address - Fax:410-997-0807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060424204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty