MEDICARE: DR. DINA D DOMALANTA-VILLALUNA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	M001402	GU

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	56685	OTHER		PIN

General Provider Information

NPI Number	:	1760539464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DINA D DOMALANTA-VILLALUNA MD

Provider Business Mailing Address
First Line	:	415 CHALAN SAN ANTONIO STE 109
Second Line	:
City	:	TAMUNING
State	:	GU
Zip	:	96913-3620
Country	:	US
Telephone Number	:	671-647-7337
Fax Number	:	671-647-7336

Provider Business Practice Location Address
First Line	:	415 CHALAN SAN ANTONIO STE 109
Second Line	:
City	:	TAMUNING
State	:	GU
Zip	:	96913-3620
Country	:	US
Telephone Number	:	671-647-7337
Fax Number	:	671-647-7336

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2007
Last Update Date	:	03/20/2024

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