Healthcare Provider Details

I. General information

NPI: 1760863286
Provider Name (Legal Business Name): GANNON TOLMAN VANALLEN D.D.S., CERT.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3481 E SUNSET RD STE 101
LAS VEGAS NV
89120-6207
US

IV. Provider business mailing address

3481 E SUNSET RD STE 101
LAS VEGAS NV
89120-6207
US

V. Phone/Fax

Practice location:
  • Phone: 702-830-4144
  • Fax:
Mailing address:
  • Phone: 702-830-4144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS3-372C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: