Provider Demographics
NPI:1649289802
Name:GOMER, MIKHAIL (DMD)
Entity type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:GOMER
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 1:525 SOUTH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843
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
Practice Address - Country:US
Practice Address - Phone:978-682-0641
Practice Address - Fax:978-682-0644
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA210831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0203131Medicaid