Provider Demographics
NPI:1891124475
Name:VILLANUEVA, DOMINIC D (DOM)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:D
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 TRUMAN ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3034
Mailing Address - Country:US
Mailing Address - Phone:505-554-8049
Mailing Address - Fax:
Practice Address - Street 1:6303 4TH ST NW
Practice Address - Street 2:STE 9
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-5853
Practice Address - Country:US
Practice Address - Phone:505-554-8049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1035171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist