Provider Demographics
NPI:1679065015
Name:GANLEY, BRIAN PATRICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:PATRICK
Last Name:GANLEY
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 1:290 BAKER AVE STE N224
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2192
Mailing Address - Country:US
Mailing Address - Phone:978-369-3831
Mailing Address - Fax:
Practice Address - Street 1:290 BAKER AVE STE N224
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2192
Practice Address - Country:US
Practice Address - Phone:978-369-3831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18579321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice