Provider Demographics
NPI:1700507415
Name:CARTER, DOMINIC
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:CARTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11031 W FAIRLANE AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-2585
Mailing Address - Country:US
Mailing Address - Phone:414-418-4338
Mailing Address - Fax:
Practice Address - Street 1:11031 W FAIRLANE AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-2585
Practice Address - Country:US
Practice Address - Phone:414-418-4338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver