Individual
DR. IVELISSE DOMINGUEZ
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
DMD
Contact information
Practice address
24 CALLE SANTIAGO PALMER SUR, GUAYAMA, PR 00784
(787) 678-7806
Mailing address
PO BOX 623, GUAYAMA, PR 00785-0623
(787) 678-7806
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
4440604
PR
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
022622800
—
FL
Enumeration date
04/22/2016
Last updated
08/06/2020
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