Provider Demographics
NPI:1437382843
Name:GOMOLKA, JEROME J (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:J
Last Name:GOMOLKA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5236 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-4209
Mailing Address - Country:US
Mailing Address - Phone:773-725-7222
Mailing Address - Fax:
Practice Address - Street 1:5236 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-4209
Practice Address - Country:US
Practice Address - Phone:773-725-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190194971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice