Healthcare Provider Details

I. General information

NPI: 1972819357
Provider Name (Legal Business Name): JENNIFER MIRANDA DOMAGALSKI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 S QUILLAN PL STE 110
KENNEWICK WA
99338-1899
US

IV. Provider business mailing address

PO BOX 190
TOPPENISH WA
98948-0190
US

V. Phone/Fax

Practice location:
  • Phone: 509-585-5437
  • Fax:
Mailing address:
  • Phone: 509-865-2395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60689948
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: