Provider Demographics
NPI:1568976231
Name:RICHARDSON, DOMINIQUE PATRICK
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:PATRICK
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CHAPMAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIAN ORCHARD
Mailing Address - State:MA
Mailing Address - Zip Code:01151-2031
Mailing Address - Country:US
Mailing Address - Phone:413-788-7231
Mailing Address - Fax:
Practice Address - Street 1:301 EDGEWATER PL STE 100
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-1281
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other