MEDICARE: MRS. MARLENE B DOMINGUEZ RDH

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	124Q00000X	Dental Hygienist	023586	NY

General Provider Information

NPI Number	:	1982719563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARLENE B DOMINGUEZ RDH

Provider Business Mailing Address
First Line	:	163 CITY ISLAND AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10464-1537
Country	:	US
Telephone Number	:	718-885-1688
Fax Number	:	718-885-9638

Provider Business Practice Location Address
First Line	:	163 CITY ISLAND AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10464-1537
Country	:	US
Telephone Number	:	718-885-1688
Fax Number	:	718-885-9638

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

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/08/2007

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