Provider Demographics
NPI:1245451368
Name:DOMINGUEZ, MARLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARLEN
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 KENNEDY BLVD E
Mailing Address - Street 2:SUITE LF
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-3901
Mailing Address - Country:US
Mailing Address - Phone:201-453-2300
Mailing Address - Fax:201-453-2233
Practice Address - Street 1:6050 KENNEDY BLVD E
Practice Address - Street 2:SUITE LF
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-3901
Practice Address - Country:US
Practice Address - Phone:201-453-2300
Practice Address - Fax:201-453-2233
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01957900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist