Provider Demographics
NPI:1932638160
Name:DOMAN, ELIZABETH (DDS)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:DOMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21934 WALTZ RD
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48164-9551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45600 JOY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-3660
Practice Address - Country:US
Practice Address - Phone:734-459-5370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-10
Last Update Date:2017-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022247122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist