Provider Demographics
NPI:1386210730
Name:GOMOLA, ZACHARY JACOB (DMD)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:JACOB
Last Name:GOMOLA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3386 NILES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8800
Mailing Address - Country:US
Mailing Address - Phone:269-281-8080
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:2021-05-27
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033072122300000X
MI29016011511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4438474OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION