Provider Demographics
NPI:1871573667
Name:KIOMENTO, DOMINIC JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:JAMES
Last Name:KIOMENTO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8950 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-8599
Mailing Address - Country:US
Mailing Address - Phone:231-775-2493
Mailing Address - Fax:231-779-7701
Practice Address - Street 1:8950 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-8599
Practice Address - Country:US
Practice Address - Phone:231-775-2493
Practice Address - Fax:231-775-2570
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086808207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080H310080OtherBC BILLING NUMBER
MIDK086808OtherSTATE LICENSE NUMBER
MI4798746OtherMOLINA BILLING NUMBER
MI4798746Medicaid
MI141754OtherPREF CHOICE BILLING
MI0M75900028Medicare ID - Type UnspecifiedMEDICARE BLLING NUMBER
MI4798746OtherMOLINA BILLING NUMBER