Provider Demographics
NPI:1912420118
Name:DOMAGALA, ALEXANDRIA
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:DOMAGALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 N PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-3076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 N PERKINS RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-3076
Practice Address - Country:US
Practice Address - Phone:217-540-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6980122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist