Provider Demographics
NPI:1992838304
Name:DOMINGUEZ, JOSE DUMERGUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:DUMERGUE
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8123 NW 161ST TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6659
Mailing Address - Country:US
Mailing Address - Phone:305-308-7458
Mailing Address - Fax:954-450-6270
Practice Address - Street 1:3 SW 129TH AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1775
Practice Address - Country:US
Practice Address - Phone:954-450-6447
Practice Address - Fax:954-450-6270
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 13058122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN 13058OtherDENTAL LICENSE