Provider Demographics
NPI:1750196176
Name:DOMEN, DEBORAH KAY (RDH)
Entity type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:KAY
Last Name:DOMEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:DEBORAH
Other - Middle Name:KAY
Other - Last Name:DISHMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:97182 HARBOR CONCOURSE CIR
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3873
Mailing Address - Country:US
Mailing Address - Phone:910-526-2333
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL 2080 CHILD ST DEPT 5000
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-0001
Practice Address - Country:US
Practice Address - Phone:912-573-4212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH043616124Q00000X
NC9243124Q00000X
FLDH31087124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist