Provider Demographics
NPI:1235860750
Name:GOUGH, BRIELLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIELLE
Middle Name:
Last Name:GOUGH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:BRIELLE
Other - Middle Name:
Other - Last Name:BOWERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1250 N FAYETTE ST APT 4441
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2788
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:138 CHURCH STREET NE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4507
Practice Address - Country:US
Practice Address - Phone:703-938-6669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD173901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice