MEDICARE: DR. JEROME J GOMOLKA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019019497	IL

General Provider Information

NPI Number	:	1437382843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEROME J GOMOLKA DDS

Provider Business Mailing Address
First Line	:	5236 W BELMONT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-4209
Country	:	US
Telephone Number	:	773-725-7222
Fax Number	:

Provider Business Practice Location Address
First Line	:	5236 W BELMONT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-4209
Country	:	US
Telephone Number	:	773-725-7222
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2009
Last Update Date	:	09/01/2009

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