Provider Demographics
NPI:1447426671
Name:MICHAEL & MARIA DOMINGOES,PA
Entity Type:Organization
Organization Name:MICHAEL & MARIA DOMINGOES,PA
Other - Org Name:ANASTASIA DENTAL ASSCOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:VALDES
Authorized Official - Last Name:DOMINGOES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-461-5788
Mailing Address - Street 1:3534 A1A S
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6899
Mailing Address - Country:US
Mailing Address - Phone:904-461-5788
Mailing Address - Fax:904-461-8558
Practice Address - Street 1:3534 A1A S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-6899
Practice Address - Country:US
Practice Address - Phone:904-461-5788
Practice Address - Fax:904-461-8558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN123121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty