Provider Demographics
NPI:1932917044
Name:DOMINO DENTAL
Entity type:Organization
Organization Name:DOMINO DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:VANPHAPHONE
Authorized Official - Middle Name:
Authorized Official - Last Name:LINAVONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-569-2367
Mailing Address - Street 1:1150 E ELDORADO PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-5502
Mailing Address - Country:US
Mailing Address - Phone:972-292-3092
Mailing Address - Fax:
Practice Address - Street 1:2425 S COCKRELL HILL RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-8103
Practice Address - Country:US
Practice Address - Phone:972-285-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental