Healthcare Provider Details

I. General information

NPI: 1225957954
Provider Name (Legal Business Name): EMANUEL DOMINGUEZ-HENDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4963 W 6TH AVE
HIALEAH FL
33012-3803
US

IV. Provider business mailing address

650 SW 88TH CT
MIAMI FL
33174-2466
US

V. Phone/Fax

Practice location:
  • Phone: 305-558-1171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN32202
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: