Healthcare Provider Details

I. General information

NPI: 1508837980
Provider Name (Legal Business Name): JAIME SALAS DOMINGUEZ D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1166 K ST
BRAWLEY CA
92227-2737
US

IV. Provider business mailing address

1166 K ST
BRAWLEY CA
92227-2737
US

V. Phone/Fax

Practice location:
  • Phone: 760-344-3583
  • Fax: 760-344-8480
Mailing address:
  • Phone: 760-344-3583
  • Fax: 760-344-8480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number37097
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: