Provider Demographics
NPI:1255816807
Name:BANUELOS, DOMINOE NICHOLE (DH)
Entity type:Individual
Prefix:
First Name:DOMINOE
Middle Name:NICHOLE
Last Name:BANUELOS
Suffix:
Gender:F
Credentials:DH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18159 E 44TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80249-7602
Mailing Address - Country:US
Mailing Address - Phone:303-669-0624
Mailing Address - Fax:
Practice Address - Street 1:3705 E COLFAX AVE UNIT 101
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-1810
Practice Address - Country:US
Practice Address - Phone:303-399-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-29
Last Update Date:2018-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002025261124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist