Provider Demographics
NPI:1477729747
Name:O'BRIEN, GARY R (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:O'BRIEN
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 1:411 N CENTRAL AVE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2081
Mailing Address - Country:US
Mailing Address - Phone:818-956-0639
Mailing Address - Fax:818-246-1542
Practice Address - Street 1:411 N CENTRAL AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2081
Practice Address - Country:US
Practice Address - Phone:818-956-0639
Practice Address - Fax:818-246-1542
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29639122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist