Provider Demographics
NPI:1790788487
Name:GALLUP, BRUCE V (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:V
Last Name:GALLUP
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:2005-05-27
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME32231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME269850099Medicaid
MEMM4339Medicare ID - Type Unspecified
ME269850099Medicaid