Provider Demographics
NPI:1043030190
Name:SUBER, DOMINIQUE SHANEY (RDHAP)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:SHANEY
Last Name:SUBER
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3175 PUFFIN CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-8914
Mailing Address - Country:US
Mailing Address - Phone:925-421-8302
Mailing Address - Fax:
Practice Address - Street 1:3175 PUFFIN CIR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-8914
Practice Address - Country:US
Practice Address - Phone:925-421-8302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP1092124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist