Provider Demographics
NPI:1184872970
Name:BRENNER, GARY NEAL (DMD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:NEAL
Last Name:BRENNER
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 1:97 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-3309
Mailing Address - Country:US
Mailing Address - Phone:631-283-6362
Mailing Address - Fax:
Practice Address - Street 1:97 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-3309
Practice Address - Country:US
Practice Address - Phone:631-283-6362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0403601223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics