Provider Demographics
NPI:1972670271
Name:DAGOSTINO, DOMINICK ANTHONY JR (DC)
Entity type:Individual
Prefix:DR
First Name:DOMINICK
Middle Name:ANTHONY
Last Name:DAGOSTINO
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 MANNER AVE
Mailing Address - Street 2:
Mailing Address - City:GARFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07026-1418
Mailing Address - Country:US
Mailing Address - Phone:973-772-0099
Mailing Address - Fax:973-772-0099
Practice Address - Street 1:96 MANNER AVE
Practice Address - Street 2:
Practice Address - City:GARFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07026-1418
Practice Address - Country:US
Practice Address - Phone:973-772-0099
Practice Address - Fax:973-772-0099
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00541800111NS0005X
NYX009210-0111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7971907Medicaid
NJ22-365-5167OtherTAX ID
NJ22-365-5167OtherTAX ID
NJU74500Medicare UPIN