Provider Demographics
NPI:1871162669
Name:DOMICO, ALYSSA MARIE (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:MARIE
Last Name:DOMICO
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 CAMPUS DR STE 245
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2678
Mailing Address - Country:US
Mailing Address - Phone:763-383-1788
Mailing Address - Fax:
Practice Address - Street 1:2805 CAMPUS DR STE 245
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2678
Practice Address - Country:US
Practice Address - Phone:763-383-1788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2024-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14939122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist