Provider Demographics
NPI:1821113176
Name:ESPIRITU, DOMINGO LARA (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOMINGO
Middle Name:LARA
Last Name:ESPIRITU
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 1:180 DOW AVE
Mailing Address - Street 2:
Mailing Address - City:ISELIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08830-1845
Mailing Address - Country:US
Mailing Address - Phone:732-283-2242
Mailing Address - Fax:
Practice Address - Street 1:180 DOW AVE
Practice Address - Street 2:
Practice Address - City:ISELIN
Practice Address - State:NJ
Practice Address - Zip Code:08830-1845
Practice Address - Country:US
Practice Address - Phone:732-283-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0369361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00731315Medicaid