Provider Demographics
NPI:1215332077
Name:GLENN L. DOMINGUEZ, D.M.D., LLC
Entity type:Organization
Organization Name:GLENN L. DOMINGUEZ, D.M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:LEGASPI
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-766-9122
Mailing Address - Street 1:219 CASS AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-4736
Mailing Address - Country:US
Mailing Address - Phone:401-766-9122
Mailing Address - Fax:401-766-1110
Practice Address - Street 1:219 CASS AVE
Practice Address - Street 2:SUITE E
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4736
Practice Address - Country:US
Practice Address - Phone:401-766-9122
Practice Address - Fax:401-766-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN02402261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental