Provider Demographics
NPI:1801145511
Name:FUFIDIO, DOMINIQUE MARIE (DDS)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MARIE
Last Name:FUFIDIO
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 1:3100 MONTICELLO AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-3441
Mailing Address - Country:US
Mailing Address - Phone:214-380-9071
Mailing Address - Fax:
Practice Address - Street 1:3100 MONTICELLO AVE STE 110
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-3441
Practice Address - Country:US
Practice Address - Phone:214-380-9071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28343122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist