Provider Demographics
NPI:1336631084
Name:DOMINGUEZ, CASEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:
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 1:6515 W PLEASANT WAY
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8427
Mailing Address - Country:US
Mailing Address - Phone:972-415-9308
Mailing Address - Fax:
Practice Address - Street 1:3920 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-1809
Practice Address - Country:US
Practice Address - Phone:885-993-5543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR42691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice