MEDICARE: DR. BRIAN JOSEPH GAMBLA D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019-022092	IL

General Provider Information

NPI Number	:	1770614778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN JOSEPH GAMBLA D.D.S.

Provider Business Mailing Address
First Line	:	7350 W COLLEGE DR STE 105
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1187
Country	:	US
Telephone Number	:	708-448-3323
Fax Number	:	708-448-3478

Provider Business Practice Location Address
First Line	:	7350 W COLLEGE DR STE 105
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1187
Country	:	US
Telephone Number	:	708-448-3323
Fax Number	:	708-448-3478

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	10/27/2014

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