Provider Demographics
NPI:1497801500
Name:DOMINGO, JOHN RELIGIOSO
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RELIGIOSO
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2670 S JONES BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-5633
Mailing Address - Country:US
Mailing Address - Phone:702-880-9527
Mailing Address - Fax:
Practice Address - Street 1:2670 S JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5633
Practice Address - Country:US
Practice Address - Phone:702-880-9527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4076122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist