Healthcare Provider Details

I. General information

NPI: 1982964953
Provider Name (Legal Business Name): MAANGELA P DOMINGUEZ, DDS, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 SPRINGS RD
VALLEJO CA
94591-5518
US

IV. Provider business mailing address

5890 OLINDA RD
EL SOBRANTE CA
94803-3544
US

V. Phone/Fax

Practice location:
  • Phone: 707-647-1072
  • Fax:
Mailing address:
  • Phone: 310-748-0419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number50902
License Number StateCA

VIII. Authorized Official

Name: MAANGELA PEREZ DOMINGUEZ
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 707-647-1072