Provider Demographics
NPI:1790262665
Name:D'ANTHONY, DOMINIQUE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:D'ANTHONY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL MEDICAL CENTER 34800 BOB WILSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5000
Mailing Address - Country:US
Mailing Address - Phone:908-763-1681
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CENTER 34800 BOB WILSON DRIVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5000
Practice Address - Country:US
Practice Address - Phone:908-763-1681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041870122300000X
UT11157497-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist