Provider Demographics
NPI:1023713740
Name:DOMINGUEZ FAMILY DENTAL, CSP
Entity type:Organization
Organization Name:DOMINGUEZ FAMILY DENTAL, CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IVELISSE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ REVERON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-678-7806
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00785-0623
Mailing Address - Country:US
Mailing Address - Phone:787-866-3631
Mailing Address - Fax:787-866-8690
Practice Address - Street 1:CALLE SANTIAGO PALMER 24 SUR
Practice Address - Street 2:N/A
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784
Practice Address - Country:US
Practice Address - Phone:787-866-3631
Practice Address - Fax:787-866-8690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-03
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty