Provider Demographics
NPI:1497993026
Name:DOMAGALA, DANIEL MICHAL (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:MICHAL
Last Name:DOMAGALA
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 N. MAJOR AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634
Mailing Address - Country:US
Mailing Address - Phone:773-777-1111
Mailing Address - Fax:773-777-0730
Practice Address - Street 1:3208 N. MAJOR AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634
Practice Address - Country:US
Practice Address - Phone:773-777-1111
Practice Address - Fax:773-777-0730
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190278661223P0700X
IL019.027866122300000X
WI6468115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0700XDental ProvidersDentistProsthodontics