Healthcare Provider Details

I. General information

NPI: 1982969937
Provider Name (Legal Business Name): KENNETH LEE DOMINGUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 WILDCLIFF PKWY NE
ATLANTA GA
30329-3464
US

IV. Provider business mailing address

1229 WILDCLIFF PKWY NE
ATLANTA GA
30329-3464
US

V. Phone/Fax

Practice location:
  • Phone: 404-323-3419
  • Fax:
Mailing address:
  • Phone: 404-323-3419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License NumberG66887
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: