Provider Demographics
NPI:1609974047
Name:AGOSTIN, DOMINICK PETER (DDS)
Entity Type:Individual
Prefix:
First Name:DOMINICK
Middle Name:PETER
Last Name:AGOSTIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 OLD RIDGEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-3013
Mailing Address - Country:US
Mailing Address - Phone:203-762-9907
Mailing Address - Fax:203-762-7002
Practice Address - Street 1:15 OLD RIDGEFIELD RD
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-3013
Practice Address - Country:US
Practice Address - Phone:203-762-9907
Practice Address - Fax:203-762-7002
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT45841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice