Provider Demographics
NPI:1902224975
Name:DEDOMENICO, DUSTIN (DMD MS)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:DEDOMENICO
Suffix:
Gender:M
Credentials:DMD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11012 N DALE MABRY HWY STE 302
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-3821
Mailing Address - Country:US
Mailing Address - Phone:813-961-1414
Mailing Address - Fax:
Practice Address - Street 1:11012 N DALE MABRY HWY STE 302
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-3821
Practice Address - Country:US
Practice Address - Phone:813-961-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2016-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 9443122300000X
FLDN207271223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist