Provider Demographics
NPI:1124652540
Name:GALLIANI, JUSTIN PHILLIP (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:PHILLIP
Last Name:GALLIANI
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 1:3605 CORBETT ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-6601
Mailing Address - Country:US
Mailing Address - Phone:707-694-6032
Mailing Address - Fax:
Practice Address - Street 1:38801 ACADEMIC DRIVE
Practice Address - Street 2:SUITE B & C
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5660
Practice Address - Country:US
Practice Address - Phone:707-694-6032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11268122300000X
CA108680122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist