Healthcare Provider Details

I. General information

NPI: 1245495951
Provider Name (Legal Business Name): DANIEL JOHN DOMINGUE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BEAULLIEU DR. BLDG #2
LAFAYETTE LA
70508
US

IV. Provider business mailing address

200 BEAULLIEU DR. BLDG #2
LAFAYETTE LA
70508
US

V. Phone/Fax

Practice location:
  • Phone: 337-235-1523
  • Fax: 337-235-0699
Mailing address:
  • Phone: 337-235-1523
  • Fax: 337-235-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number053985
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5893
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: