Provider Demographics
NPI:1851395321
Name:GALLAGHER, DALE MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:MARK
Last Name:GALLAGHER
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 1:12210 PECAN ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-6109
Mailing Address - Country:US
Mailing Address - Phone:512-258-1636
Mailing Address - Fax:
Practice Address - Street 1:12210 PECAN ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-6109
Practice Address - Country:US
Practice Address - Phone:512-258-1636
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX143991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14399Medicare UPIN