Provider Demographics
NPI:1982803078
Name:MICHAEL G. DOMINOV, DDS PC
Entity Type:Organization
Organization Name:MICHAEL G. DOMINOV, DDS PC
Other - Org Name:LEE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:DOMINOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:413-243-0098
Mailing Address - Street 1:17 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:LEE
Mailing Address - State:MA
Mailing Address - Zip Code:01238-1629
Mailing Address - Country:US
Mailing Address - Phone:413-243-0098
Mailing Address - Fax:413-243-2663
Practice Address - Street 1:17 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:LEE
Practice Address - State:MA
Practice Address - Zip Code:01238-1629
Practice Address - Country:US
Practice Address - Phone:413-243-0098
Practice Address - Fax:413-243-2663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16758261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental