Healthcare Provider Details

I. General information

NPI: 1730106329
Provider Name (Legal Business Name): BRUCE L DOMM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 9TH AVE N
CASSELTON ND
58012-3339
US

IV. Provider business mailing address

PO BOX 6001
FARGO ND
58108-6001
US

V. Phone/Fax

Practice location:
  • Phone: 701-347-4445
  • Fax: 701-347-5276
Mailing address:
  • Phone: 701-364-3300
  • Fax: 701-364-8906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5341
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: