=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952401010
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEANA LOUISE DOMINGUEZ DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2006
-----------------------------------------------------
Last Update Date | 12/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1599 JONES ST
-----------------------------------------------------
City | GRAND FORKS AFB
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-747-5601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1599 JONES ST
-----------------------------------------------------
City | GRAND FORKS AFB
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-747-5601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | R1361
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2083X0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Physician
-----------------------------------------------------
License Number | R1361
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------