Provider Demographics
NPI:1972230423
Name:DOMINIQUE, DAVID KUFIADAN
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:KUFIADAN
Last Name:DOMINIQUE
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 1:2120 S 12TH ST APT 322
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-8116
Mailing Address - Country:US
Mailing Address - Phone:513-580-0546
Mailing Address - Fax:
Practice Address - Street 1:2120 S 12TH ST APT 322
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-8116
Practice Address - Country:US
Practice Address - Phone:513-580-0546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant