Provider Demographics
NPI:1669676052
Name:DOMINGUEZ, JORGE LUIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2751 SW 142ND CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-6571
Mailing Address - Country:US
Mailing Address - Phone:305-229-1111
Mailing Address - Fax:305-222-8866
Practice Address - Street 1:13155 SW 42ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3428
Practice Address - Country:US
Practice Address - Phone:303-222-8999
Practice Address - Fax:305-222-8866
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN124851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice