Provider Demographics
NPI:1386891380
Name:DOMINQUEZ, SERGIO (DDS)
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:DOMINQUEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 961629
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79996
Mailing Address - Country:US
Mailing Address - Phone:915-591-1709
Mailing Address - Fax:915-591-1709
Practice Address - Street 1:AV AMERICAS #750
Practice Address - Street 2:
Practice Address - City:JUAREZ
Practice Address - State:CHIH
Practice Address - Zip Code:32310
Practice Address - Country:MX
Practice Address - Phone:01152656-616-1626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1379537122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist