Provider Demographics
NPI:1548410491
Name:DOMAGALA, AGNIESZKA (DDS)
Entity Type:Individual
Prefix:DR
First Name:AGNIESZKA
Middle Name:
Last Name:DOMAGALA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14257 WATERFORD SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-9509
Mailing Address - Country:US
Mailing Address - Phone:708-655-9724
Mailing Address - Fax:
Practice Address - Street 1:1801 W. WISCONSIN AVE.
Practice Address - Street 2:MARQUETTE UNIVERSITY SCHOOL OF DENTISTRY/AEGD
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233
Practice Address - Country:US
Practice Address - Phone:414-288-7388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027819122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist