Provider Demographics
NPI:1740606748
Name:SOLOMON, DORIAN
Entity Type:Individual
Prefix:
First Name:DORIAN
Middle Name:
Last Name:SOLOMON
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:PO BOX 1357
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-1357
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:239-226-4650
Practice Address - Street 1:2232 GRAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-3717
Practice Address - Country:US
Practice Address - Phone:239-344-2344
Practice Address - Fax:239-332-3372
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20526122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011673600Medicaid