Provider Demographics
NPI:1508023649
Name:DOMINGUEZ & RUCKER FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:DOMINGUEZ & RUCKER FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:C
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:803-547-1888
Mailing Address - Street 1:575 SPRINGCREST DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-7307
Mailing Address - Country:US
Mailing Address - Phone:803-547-1888
Mailing Address - Fax:803-547-8533
Practice Address - Street 1:575 SPRINGCREST DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-7307
Practice Address - Country:US
Practice Address - Phone:803-547-1888
Practice Address - Fax:803-547-8533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC3850122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3850Medicaid