Provider Demographics
NPI:1326535261
Name:DYLAN C GAILLARD, DDS, LLC
Entity Type:Organization
Organization Name:DYLAN C GAILLARD, DDS, LLC
Other - Org Name:AUGUSTA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DYLAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GAILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-334-5052
Mailing Address - Street 1:12828 AUGUSTA AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-3733
Mailing Address - Country:US
Mailing Address - Phone:402-334-5052
Mailing Address - Fax:402-334-0215
Practice Address - Street 1:12828 AUGUSTA AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-3733
Practice Address - Country:US
Practice Address - Phone:402-334-5052
Practice Address - Fax:402-334-0215
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DYLAN C GAILLARD, DDS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental