Provider Demographics
NPI:1215039375
Name:BREEN, GARY H (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:H
Last Name:BREEN
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 1:50 MAHONEY AVE
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4836
Mailing Address - Country:US
Mailing Address - Phone:802-775-6771
Mailing Address - Fax:802-775-3116
Practice Address - Street 1:50 MAHONEY AVE
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4836
Practice Address - Country:US
Practice Address - Phone:802-775-6771
Practice Address - Fax:802-775-3116
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT6201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002413Medicaid