| Doctor Name: | DR. GINA MICHELE DOMM |
| NPI Number: | 1346530144 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | DDS |
| License Number: | |
| Business Practice Address: | 2133 Pepperrell St Building 3352 Apo, AA - 291525019 |
| Business Phone Number: | 8038956356 |
| Business Fax Number: | 8038956456 |
| Mailing Address: | 2133 Pepperrell St, Building 3352 JBSA LACKLAND |
| State: | TX |
| Postal Code: | 782365313 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 04/13/2011 |
| NPI Last Update Date: | 06/08/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 171000000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Military Health Care Provider |
| Taxonomy Specialization: | |
| Taxonomy Definition: | Active duty military health care providers not otherwise classified who need to be separately identified for operational, clinical, or administrative processes. |