Provider Demographics
NPI:1588734388
Name:MOGAVERO, DOMENICA MARIA (LAC)
Entity type:Individual
Prefix:MS
First Name:DOMENICA
Middle Name:MARIA
Last Name:MOGAVERO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:240 PROCTOR AVE
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-4923
Mailing Address - Country:US
Mailing Address - Phone:781-640-7893
Mailing Address - Fax:
Practice Address - Street 1:527 MAIN ST STE 14
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3817
Practice Address - Country:US
Practice Address - Phone:781-640-7893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212401171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist