Healthcare Provider Details

I. General information

NPI: 1124867916
Provider Name (Legal Business Name): NATHANIEL GOMOLIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date: 01/14/2025
Reactivation Date: 02/10/2025

III. Provider practice location address

37 BOYNTON AVE STE 2
PLATTSBURGH NY
12901-1268
US

IV. Provider business mailing address

200 EAST 82ND ST 23J
NEW YORK NY
10028
US

V. Phone/Fax

Practice location:
  • Phone: 518-563-5002
  • Fax: 518-205-7795
Mailing address:
  • Phone: 514-581-1297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number065524
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: