Provider Demographics
NPI:1164636270
Name:ALONZO DOMINGUEZ, OTTO RAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:OTTO
Middle Name:RAUL
Last Name:ALONZO 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 1:145 SHAW AVE
Mailing Address - Street 2:SUITE B1-B2
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-3841
Mailing Address - Country:US
Mailing Address - Phone:559-325-2175
Mailing Address - Fax:559-325-2175
Practice Address - Street 1:145 SHAW AVE
Practice Address - Street 2:SUITE B1-B2
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-3841
Practice Address - Country:US
Practice Address - Phone:559-325-2175
Practice Address - Fax:559-325-2175
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA507191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice