Provider Demographics
NPI:1396242012
Name:THOMAS, DOMINIQUE DANIELLE (DDS)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:DANIELLE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 RIDGEWOOD DR STE B
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2785
Mailing Address - Country:US
Mailing Address - Phone:419-352-2593
Mailing Address - Fax:844-224-3880
Practice Address - Street 1:1221 RIDGEWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2785
Practice Address - Country:US
Practice Address - Phone:419-352-2593
Practice Address - Fax:844-224-3880
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30-0264211223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program