Provider Demographics
NPI:1669027843
Name:SMITH, DOMINIQUE (PHLEBOTOMIST)
Entity Type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHLEBOTOMIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9225 W CHARLESTON BLVD APT 1041
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-7051
Mailing Address - Country:US
Mailing Address - Phone:702-758-2817
Mailing Address - Fax:
Practice Address - Street 1:1701 N GREEN VALLEY PKWY STE 9A
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-5991
Practice Address - Country:US
Practice Address - Phone:702-407-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
NV57346-AL-O246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant