Provider Demographics
NPI:1679660484
Name:DO, DOMINIC (DDS)
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:
Last Name:DO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:MR
Other - First Name:LUYEN
Other - Middle Name:DUC
Other - Last Name:DO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3211 N. TENAYA WAY
Mailing Address - Street 2:STE 122
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129
Mailing Address - Country:US
Mailing Address - Phone:702-641-2300
Mailing Address - Fax:702-641-2323
Practice Address - Street 1:3211 N. TENAYA WAY
Practice Address - Street 2:STE 122
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129
Practice Address - Country:US
Practice Address - Phone:702-641-2300
Practice Address - Fax:702-641-2323
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV48171223G0001X
CA532051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1356575328Medicaid