Provider Demographics
NPI:1184318776
Name:ITALIA, DOMINIC S (DDS)
Entity type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:S
Last Name:ITALIA
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 1:899 US HIGHWAY 287 STE 600
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-7319
Mailing Address - Country:US
Mailing Address - Phone:303-460-9366
Mailing Address - Fax:
Practice Address - Street 1:899 US HIGHWAY 287 STE 600
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-7319
Practice Address - Country:US
Practice Address - Phone:303-460-9366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00205662122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist