Provider Demographics
NPI:1336119528
Name:DOMARK, JEFFREY D (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:DOMARK
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 TOMCAT BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23460-2188
Mailing Address - Country:US
Mailing Address - Phone:757-953-3926
Mailing Address - Fax:
Practice Address - Street 1:1550 TOMCAT BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23460-2188
Practice Address - Country:US
Practice Address - Phone:757-953-3926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-026178122300000X
VA04014133661223E0200X
MO2010010741122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223E0200XDental ProvidersDentistEndodontics