Provider Demographics
NPI:1154426716
Name:DOMATO, DENNIS N (DMD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:N
Last Name:DOMATO
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 1:9529 NORTON COMMONS BLVD
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-7521
Mailing Address - Country:US
Mailing Address - Phone:502-425-1565
Mailing Address - Fax:
Practice Address - Street 1:12613 TAYLORSVILLE RD
Practice Address - Street 2:SUITE 117
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-4452
Practice Address - Country:US
Practice Address - Phone:502-266-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8069122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist