Provider Demographics
NPI:1417625161
Name:ANCONA, DOMINIQUE (DMD)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:ANCONA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10643 APPLE LN
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-2403
Mailing Address - Country:US
Mailing Address - Phone:909-204-1333
Mailing Address - Fax:
Practice Address - Street 1:8660 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-1692
Practice Address - Country:US
Practice Address - Phone:909-920-0696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106830122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist