Provider Demographics
NPI:1407924194
Name:DOMANSKI, TED B (DDS)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:B
Last Name:DOMANSKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19802 LOXAHATCHEE POINTE DR
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-1814
Mailing Address - Country:US
Mailing Address - Phone:561-743-0368
Mailing Address - Fax:
Practice Address - Street 1:1212 US HIGHWAY 1
Practice Address - Street 2:OLD PORT COVE PLAZA
Practice Address - City:N PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-3536
Practice Address - Country:US
Practice Address - Phone:561-626-3474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL0011250122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist