Provider Demographics
NPI:1023590452
Name:BOULDIN, DOMINIQUE
Entity type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:
Last Name:BOULDIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 HIGHLAND FARM CT
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-3301
Mailing Address - Country:US
Mailing Address - Phone:240-718-8595
Mailing Address - Fax:
Practice Address - Street 1:11136 SAINT CHRISTOPHER DRIVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695
Practice Address - Country:US
Practice Address - Phone:240-718-8595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-01
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver