Provider Demographics
NPI:1033401708
Name:DOMINGO, MARJORIE (DDS)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 DARLING CABIN ROAD
Mailing Address - Street 2:
Mailing Address - City:GARDEN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95633
Mailing Address - Country:US
Mailing Address - Phone:805-870-5540
Mailing Address - Fax:
Practice Address - Street 1:7220 DARLING CABIN RD
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95633-9745
Practice Address - Country:US
Practice Address - Phone:805-870-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA435951223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry