Healthcare Provider Details

I. General information

NPI: 1790844041
Provider Name (Legal Business Name): GARY W VOLLAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 SOUTH 4TH
BASIN WY
82410-0332
US

IV. Provider business mailing address

PO BOX 332 502 S. 4TH
BASIN WY
82410-0332
US

V. Phone/Fax

Practice location:
  • Phone: 307-568-2047
  • Fax:
Mailing address:
  • Phone: 307-568-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT-DO-184236
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: