Provider Demographics
NPI:1164985024
Name:DHALIWAL, GAGAN (DMD)
Entity Type:Individual
Prefix:
First Name:GAGAN
Middle Name:
Last Name:DHALIWAL
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 1:89 E DEDHAM ST APT 902
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-3577
Mailing Address - Country:US
Mailing Address - Phone:617-832-5025
Mailing Address - Fax:
Practice Address - Street 1:100 GROSSMAN DR STE 210
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4961
Practice Address - Country:US
Practice Address - Phone:781-412-7901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18591751223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program