Provider Demographics
NPI:1508396698
Name:DOMINGUEZ, CORI JEANEL (DMD)
Entity Type:Individual
Prefix:
First Name:CORI
Middle Name:JEANEL
Last Name:DOMINGUEZ
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 1:13601 WENONAH AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-4187
Mailing Address - Country:US
Mailing Address - Phone:505-205-0744
Mailing Address - Fax:
Practice Address - Street 1:3740 COORS BLVD NW STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-4762
Practice Address - Country:US
Practice Address - Phone:505-836-1280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD46951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice