Provider Demographics
NPI:1356311302
Name:BROUSELL, GARY M (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:BROUSELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 WARDELL CIR
Mailing Address - Street 2:
Mailing Address - City:OCEANPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07757-1610
Mailing Address - Country:US
Mailing Address - Phone:732-747-0993
Mailing Address - Fax:732-747-0961
Practice Address - Street 1:21 GILBERT STREET
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07724
Practice Address - Country:US
Practice Address - Phone:732-747-0993
Practice Address - Fax:732-747-0961
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ106901223S0112X
NJ22DI0106000204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1863401Medicaid
NJ1863401Medicaid
NJU24792Medicare UPIN