Provider Demographics
NPI:1154400224
Name:DOMINICK, FREDERICK WAYDE (DMD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:WAYDE
Last Name:DOMINICK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 AMICKS FERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036
Mailing Address - Country:US
Mailing Address - Phone:803-345-3599
Mailing Address - Fax:
Practice Address - Street 1:123 AMICKS FERRY ROAD
Practice Address - Street 2:DR FREDERICK WAYDE DOMINICK
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036
Practice Address - Country:US
Practice Address - Phone:803-345-3599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2637122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist