MEDICARE: DOMINGUEZ & RUCKER FAMILY DENTISTRY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	SC3850	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508023649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOMINGUEZ & RUCKER FAMILY DENTISTRY LLC

Provider Business Mailing Address
First Line	:	575 SPRINGCREST DRIVE
Second Line	:	SUITE A
City	:	FORT MILL
State	:	SC
Zip	:	29715-7307
Country	:	US
Telephone Number	:	803-547-1888
Fax Number	:	803-547-8533

Provider Business Practice Location Address
First Line	:	575 SPRINGCREST DRIVE
Second Line	:	SUITE A
City	:	FORT MILL
State	:	SC
Zip	:	29715-7307
Country	:	US
Telephone Number	:	803-547-1888
Fax Number	:	803-547-8533

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	MS. LORI C DOMINGUEZ
Credential	:	DDS
Telephone Number	:	803-547-1888

Provider Enumeration Date	:	05/16/2008
Last Update Date	:	01/23/2017

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