Provider Demographics
NPI:1760258412
Name:GEORGE, DOMINIC (LDO)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:GEORGE
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2185 PINE ST SE
Mailing Address - Street 2:
Mailing Address - City:EAST SPARTA
Mailing Address - State:OH
Mailing Address - Zip Code:44626-9571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:231 BLUEBELL DR SW
Practice Address - Street 2:
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663-9601
Practice Address - Country:US
Practice Address - Phone:330-339-6016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.017666-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician