=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780794917
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID JAIME DOMINGUEZ DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17240 MILL FOREST RD STE A
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-280-9149
-----------------------------------------------------
Fax | 281-280-0732
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17240 MILL FOREST RD STE A
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-280-9149
-----------------------------------------------------
Fax | 281-280-0732
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 014746
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------