Provider Demographics
NPI:1790379386
Name:FONTAINE, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HIGHLAND AVE # B
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755-1525
Mailing Address - Country:US
Mailing Address - Phone:203-252-6445
Mailing Address - Fax:
Practice Address - Street 1:1 ROPE FERRY RD
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755-1421
Practice Address - Country:US
Practice Address - Phone:603-650-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-24
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program