Provider Demographics
NPI:1780357608
Name:GOMOLA, ALEXANDRIA (DMD)
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:GOMOLA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ALEXANDRIA
Other - Middle Name:
Other - Last Name:OSTROWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:906 LIONS PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1019
Mailing Address - Country:US
Mailing Address - Phone:708-990-7110
Mailing Address - Fax:
Practice Address - Street 1:3386 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8800
Practice Address - Country:US
Practice Address - Phone:269-281-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002641-151223G0001X
MI29016011511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice