Individual
DR. JODY B HERSCHENHORN-DOMINICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DDS
Contact information
Practice address
483 W. SEED FARM RD., SACATON, AZ 85147-0038
(602) 528-1200
(602) 528-1296
Mailing address
PO BOX 38, GILA RIVER HEALTH CARE CORPORATION, SACATON, AZ 85147-0038
(602) 528-1200
(602) 528-1255
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
5247
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
771768
—
AZ
01
—
873865
UNITED CONCORDIA DENTAL
AZ
01
—
AZ0479240
BCBS PROVIDER NUMBER
AZ
Enumeration date
10/31/2006
Last updated
03/08/2012
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