Provider Demographics
NPI:1144776923
Name:DO, DOMINIC (MS, DDS)
Entity type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:
Last Name:DO
Suffix:
Gender:M
Credentials:MS, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8370 ICE CRYSTAL DRIVE
Mailing Address - Street 2:A1
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-2061
Mailing Address - Country:US
Mailing Address - Phone:443-631-4923
Mailing Address - Fax:
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:USS OSBORNE
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064
Practice Address - Country:US
Practice Address - Phone:443-631-4923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2021-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16006122300000X
MADN18587211223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No122300000XDental ProvidersDentist