Provider Demographics
NPI:1770669939
Name:HERSCHENHORN-DOMINICK, JODY B (DDS)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:B
Last Name:HERSCHENHORN-DOMINICK
Suffix:
Gender:F
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:PO BOX 38
Mailing Address - Street 2:GILA RIVER HEALTH CARE CORPORATION
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85147-0038
Mailing Address - Country:US
Mailing Address - Phone:602-528-1200
Mailing Address - Fax:602-528-1255
Practice Address - Street 1:483 W. SEED FARM RD.
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85147-0038
Practice Address - Country:US
Practice Address - Phone:602-528-1200
Practice Address - Fax:602-528-1296
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ52471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0479240OtherBCBS PROVIDER NUMBER
AZ873865OtherUNITED CONCORDIA DENTAL
AZ771768Medicaid