Provider Demographics
NPI:1013373620
Name:A. DOMINGUEZ DDS PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:A. DOMINGUEZ DDS PROFESSIONAL DENTAL CORPORATION
Other - Org Name:AD DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-691-0121
Mailing Address - Street 1:290 LANDIS AVE
Mailing Address - Street 2:STE A&B
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2636
Mailing Address - Country:US
Mailing Address - Phone:619-691-0121
Mailing Address - Fax:
Practice Address - Street 1:290 LANDIS AVE
Practice Address - Street 2:STE A&B
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2636
Practice Address - Country:US
Practice Address - Phone:619-691-0121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA505951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty