Healthcare Provider Details

I. General information

NPI: 1073800520
Provider Name (Legal Business Name): DOMINIC MOREL-MAYNARD D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15340 S JOG RD STE 100
DELRAY BEACH FL
33446-2170
US

IV. Provider business mailing address

5720 FOX HOLLOW DR APT C
BOCA RATON FL
33486-8928
US

V. Phone/Fax

Practice location:
  • Phone: 561-495-2099
  • Fax:
Mailing address:
  • Phone: 917-703-8220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN 21761
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN21761
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2018010876
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: