MEDICARE: DR. LUIS ALBERTO DOMINGUEZ CARRAZQUILLO DDS

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	1223G0001X	General Practice Dentistry	1099	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	40624	OTHER	PR	CRUZ AZUL
2	1099	OTHER	PR	MENONITA
3	26016	OTHER	PR	AMERICAN HEALTH
4	4-1072	OTHER	PR	TRIPLE SSS
5	1099	OTHER	PR	UIA
6	6540025	OTHER	PR	HUMANA
7	8634	OTHER	PR	IMC

General Provider Information

NPI Number	:	1659379303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUIS ALBERTO DOMINGUEZ CARRAZQUILLO DDS

Provider Business Mailing Address
First Line	:	PO BOX 623
Second Line	:
City	:	GUAYAMA
State	:	PR
Zip	:	00785-0623
Country	:	US
Telephone Number	:	787-866-3631
Fax Number	:	787-866-8690

Provider Business Practice Location Address
First Line	:	CALLE PALMER SUR #24
Second Line	:
City	:	GUAYAMA
State	:	PR
Zip	:	00784-7610
Country	:	US
Telephone Number	:	787-866-3631
Fax Number	:	787-866-8690

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/08/2007

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