Provider Demographics
NPI:1760520670
Name:GARY BROUSELL, D.D.S.PA
Entity Type:Organization
Organization Name:GARY BROUSELL, D.D.S.PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROUSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:732-747-0993
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:732-539-5600
Mailing Address - Fax:
Practice Address - Street 1:21 GILBERT ST.
Practice Address - Street 2:
Practice Address - City:TINTON FALL
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI106901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1863401Medicaid