Individual
DALLAS LEE DOMANGUE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2500 N STATE ST, JACKSON, MS 39216-4500
(601) 984-1000
Mailing address
127 PARKWAY DR APT 1103, JACKSON, MS 39211-4212
(985) 860-6961
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
T-4248
MS
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
03/26/2021
Last updated
07/03/2021
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