Provider Demographics
NPI:1518596246
Name:HINES, DOMINIQUE MICHELLE GRASTY (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MICHELLE GRASTY
Last Name:HINES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4581 S COBB DR SE STE 100
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6906
Mailing Address - Country:US
Mailing Address - Phone:770-801-5000
Mailing Address - Fax:770-435-6690
Practice Address - Street 1:4581 S COBB DR SE STE 100
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6906
Practice Address - Country:US
Practice Address - Phone:770-801-5000
Practice Address - Fax:770-435-6690
Is Sole Proprietor?:No
Enumeration Date:2020-04-04
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA95066208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program