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Dr. Dominick Detommaso
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NPI Number Detailed Information
Provider Information:
Name: | Dr. Dominick Detommaso |
Gender: | M |
Provider License Number If Given: | 07000410A |
NPI Information:
NPI: | 1013910041 |
Entity Type (Individual or Organization): |
1-ind |
Enumeration Date: | 5/23/2005 |
Last Update Date: | 3/22/2016 |
Provider Business Mailing Address:
Address: | 7601 W JEFFERSON BLVD Fort Wayne, IN 46804 |
Phone Number: | 2604368686 |
Fax Number: | 2604368585 |
Provider Business Practice Location Address:
Address: | 7601 W JEFFERSON BLVD Fort Wayne, IN 46804 |
Phone Number: | 2604368686 |
Fax Number: | 2604368585 |
Provider Taxonomy:
Primary: | 213E00000X |
Secondary (if any): | 213ES0103X |
State: | IN |