Provider Demographics
NPI:1639207475
Name:MIKHAIL GOMER DMD PC
Entity Type:Organization
Organization Name:MIKHAIL GOMER DMD PC
Other - Org Name:MOUNT VERNON DENTAL SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKHAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-682-0641
Mailing Address - Street 1:525 SOUTH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-2837
Mailing Address - Country:US
Mailing Address - Phone:978-682-0641
Mailing Address - Fax:978-682-0644
Practice Address - Street 1:525 SOUTH BROADWAY
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-2837
Practice Address - Country:US
Practice Address - Phone:978-682-0641
Practice Address - Fax:978-682-0644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA210831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9747401Medicaid