Healthcare Provider Details

I. General information

NPI: 1316351372
Provider Name (Legal Business Name): 3D SPORTS MEDICINE & JOINT CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 CLASSIC CT STE 104
MELBOURNE FL
32940-8279
US

IV. Provider business mailing address

640 CLASSIC CT STE 104
MELBOURNE FL
32940-8279
US

V. Phone/Fax

Practice location:
  • Phone: 321-610-8939
  • Fax: 321-622-8728
Mailing address:
  • Phone: 321-610-8939
  • Fax: 321-622-8728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME110378
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberME110378
License Number StateFL

VIII. Authorized Official

Name: DR. DAVID E DOMINGUEZ
Title or Position: OWNER
Credential: M.D.
Phone: 321-610-8939