Provider Demographics
NPI:1629809777
Name:DOMINGUEZ CASTILLO, JENY FERNANDA
Entity type:Individual
Prefix:
First Name:JENY
Middle Name:FERNANDA
Last Name:DOMINGUEZ CASTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 HASCALL DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-4801
Mailing Address - Country:US
Mailing Address - Phone:678-467-8025
Mailing Address - Fax:
Practice Address - Street 1:2900 S COBB DR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-7859
Practice Address - Country:US
Practice Address - Phone:470-282-0051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1235651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice