Provider Demographics
NPI:1770614778
Name:GAMBLA, BRIAN JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JOSEPH
Last Name:GAMBLA
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 1:7350 W COLLEGE DR STE 105
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1187
Mailing Address - Country:US
Mailing Address - Phone:708-448-3323
Mailing Address - Fax:708-448-3478
Practice Address - Street 1:7350 W COLLEGE DR STE 105
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1187
Practice Address - Country:US
Practice Address - Phone:708-448-3323
Practice Address - Fax:708-448-3478
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0220921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice