Provider Demographics
NPI:1427217918
Name:DOMENELLA, DAVID DWIGHT (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:DWIGHT
Last Name:DOMENELLA
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 1:9716 US HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IL
Mailing Address - Zip Code:60071-9253
Mailing Address - Country:US
Mailing Address - Phone:815-678-2800
Mailing Address - Fax:815-678-4807
Practice Address - Street 1:9716 US HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IL
Practice Address - Zip Code:60071-9253
Practice Address - Country:US
Practice Address - Phone:815-678-2800
Practice Address - Fax:815-678-4807
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.019680122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist