Provider Demographics
NPI:1316045578
Name:DOMINGUEZ, GLENN LEGASPI (DMD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:LEGASPI
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 OSPREY DR
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-1340
Mailing Address - Country:US
Mailing Address - Phone:401-885-1225
Mailing Address - Fax:
Practice Address - Street 1:219 CASS AVE
Practice Address - Street 2:SUITE E
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4741
Practice Address - Country:US
Practice Address - Phone:401-766-9122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN024021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice