Provider Demographics
NPI:1194125351
Name:JOHN M GALLUCCI DMD PC
Entity type:Organization
Organization Name:JOHN M GALLUCCI DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:GALLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-657-7770
Mailing Address - Street 1:1017 MOLALLA AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-3772
Mailing Address - Country:US
Mailing Address - Phone:503-657-7770
Mailing Address - Fax:503-657-9832
Practice Address - Street 1:1017 MOLALLA AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-3772
Practice Address - Country:US
Practice Address - Phone:503-657-7770
Practice Address - Fax:503-657-9832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-25
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD93041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR7186950001Medicare NSC