Provider Demographics
NPI:1427163401
Name:GOWASACK, BRIAN JOHN (DDS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOHN
Last Name:GOWASACK
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 1:5340 GA HWY 20 SOUTH
Mailing Address - Street 2:SUITE 1
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016
Mailing Address - Country:US
Mailing Address - Phone:770-788-9900
Mailing Address - Fax:770-788-1040
Practice Address - Street 1:5340 GA HWY 20 SOUTH
Practice Address - Street 2:SUITE 1
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016
Practice Address - Country:US
Practice Address - Phone:770-788-9900
Practice Address - Fax:770-788-1040
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10324122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist