Provider Demographics
NPI:1639290315
Name:DOMINA, EDWARD (DDS)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:DOMINA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8651 WEST 159TH STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ORLAND PK
Mailing Address - State:IL
Mailing Address - Zip Code:60462
Mailing Address - Country:US
Mailing Address - Phone:708-429-0900
Mailing Address - Fax:708-460-8096
Practice Address - Street 1:8651 WEST 159TH STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:ORLAND PK
Practice Address - State:IL
Practice Address - Zip Code:60462
Practice Address - Country:US
Practice Address - Phone:708-429-0900
Practice Address - Fax:708-460-8096
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019A153551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice