Basic Information
| Provider Information | |||||||||
| NPI: | 1205413010 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMANGUE | ||||||||
| FirstName: | DALLAS | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 127 PARKWAY DR APT 1103 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392114212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858606961 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019841000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2021 | ||||||||
| LastUpdateDate: | 07/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | T-4248 | MS | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.