Provider Demographics
NPI:1407833668
Name:GALLAGHER, BRIAN L (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
Last Name:GALLAGHER
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 1:211 MOUNT AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-8521
Mailing Address - Country:US
Mailing Address - Phone:207-514-7171
Mailing Address - Fax:207-514-7177
Practice Address - Street 1:211 MOUNT AUBURN AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-8521
Practice Address - Country:US
Practice Address - Phone:207-514-7171
Practice Address - Fax:207-514-7177
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME31191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME263930099Medicaid
MET31373Medicare UPIN
ME263930099Medicaid