=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316351372
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 3D SPORTS MEDICINE & JOINT CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2014
-----------------------------------------------------
Last Update Date | 03/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 640 CLASSIC CT STE 104
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-8279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-610-8939
-----------------------------------------------------
Fax | 321-622-8728
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 640 CLASSIC CT STE 104
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-8279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-610-8939
-----------------------------------------------------
Fax | 321-622-8728
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAVID E DOMINGUEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 321-610-8939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | ME110378
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | ME110378
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------