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General NPI Number Information
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NPI Number | 1386428472
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Entity Type | Organization
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Legal Business Name | KRISTIN DOMINGUEZ DO PLLC
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Dates
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Enumeration Date | 08/21/2023
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Last Update Date | 08/21/2023
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Provider Practice Location Address
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Address Line | 5104 JERICHO RD
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City | COLUMBIA
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State | MD
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Zip | 21044-5410
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Country | US
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Telephone | 305-318-0244
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Fax |
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Provider Business Mailing Address
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Address Line | 4380 MONTGOMERY RD STE B
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City | ELLICOTT CITY
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State | MD
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Zip | 21043-6112
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KRISTIN DOMINGUEZ
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Credential | DO
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Telephone | 305-318-0244
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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