Provider Demographics
NPI:1124799861
Name:DALFONSO, DOMINIC (PT)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:DALFONSO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1085 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-1135
Mailing Address - Country:US
Mailing Address - Phone:716-345-7481
Mailing Address - Fax:
Practice Address - Street 1:1085 SMITH RD
Practice Address - Street 2:
Practice Address - City:EAST AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14051-1135
Practice Address - Country:US
Practice Address - Phone:716-345-7481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-31944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist