Provider Demographics
NPI:1134579162
Name:DOMINGUEZ, EDWARD (DMD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 ROUTE 17
Mailing Address - Street 2:12TH FLOOR
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2574
Mailing Address - Country:US
Mailing Address - Phone:201-549-8827
Mailing Address - Fax:
Practice Address - Street 1:201 ROUTE 17
Practice Address - Street 2:12TH FLOOR
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2574
Practice Address - Country:US
Practice Address - Phone:201-549-8827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02642300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist