Healthcare Provider Details

I. General information

NPI: 1255072559
Provider Name (Legal Business Name): BRENNAN PATRICK DAGLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2022
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 MELNEA CASS BLVD
BOSTON MA
02119-4401
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE STE 2
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-2080
  • Fax:
Mailing address:
  • Phone: 617-414-2080
  • Fax: 617-414-2090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number1028348
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1028348
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: