Healthcare Provider Details

I. General information

NPI: 1770964116
Provider Name (Legal Business Name): BENJAMIN T GALLION DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S ELLIOTT AVE STE A
AURORA MO
65605-2154
US

IV. Provider business mailing address

1402 S ELLIOTT AVE STE A
AURORA MO
65605-2154
US

V. Phone/Fax

Practice location:
  • Phone: 417-678-5958
  • Fax: 417-678-1519
Mailing address:
  • Phone: 417-678-5958
  • Fax: 417-678-1519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2015016955
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: