1780670612 NPI number — MR. DOMINIC ANTHONY CANDIDO PHD

Table of content: MR. DOMINIC ANTHONY CANDIDO PHD (NPI 1780670612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780670612 NPI number — MR. DOMINIC ANTHONY CANDIDO PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANDIDO
Provider First Name:
DOMINIC
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CANDIDO
Provider Other First Name:
DOMINIC
Provider Other Middle Name:
ANTHONY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1780670612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
67 ETNA ROAD
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-448-0055
Provider Business Mailing Address Fax Number:
603-727-9042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
67 ETNA ROAD
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-448-0055
Provider Business Practice Location Address Fax Number:
603-727-9042
Provider Enumeration Date:
09/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  NY10699 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: NH 1126 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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