Provider Demographics
NPI:1679623490
Name:KALLUS, BRIAN GENE (DMD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:GENE
Last Name:KALLUS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4228
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4228
Mailing Address - Country:US
Mailing Address - Phone:541-383-3005
Mailing Address - Fax:541-383-1883
Practice Address - Street 1:2084 NE PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6077
Practice Address - Country:US
Practice Address - Phone:541-383-3005
Practice Address - Fax:541-383-1883
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist