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General NPI Number Information
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NPI Number | 1427217918
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Entity Type | Individual
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Provider Name | DAVID DWIGHT DOMENELLA DDS
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Gender | Male
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Dates
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Enumeration Date | 06/09/2008
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Last Update Date | 10/11/2012
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Provider Practice Location Address
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Address Line | 9716 US HIGHWAY 12
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City | RICHMOND
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State | IL
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Zip | 60071-9253
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Country | US
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Telephone | 815-678-2800
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Fax | 815-678-4807
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Provider Business Mailing Address
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Address Line | 9716 US HIGHWAY 12
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City | RICHMOND
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State | IL
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Zip | 60071-9253
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Country | US
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Telephone | 815-678-2800
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Fax | 815-678-4807
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.019680
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License Number State | IL
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