Provider Demographics
NPI:1700947702
Name:GOLLAHER, BOB G SR
Entity type:Individual
Prefix:DR
First Name:BOB
Middle Name:G
Last Name:GOLLAHER
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 S MERIDIAN
Mailing Address - Street 2:5
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-3701
Mailing Address - Country:US
Mailing Address - Phone:253-864-0310
Mailing Address - Fax:
Practice Address - Street 1:3850 S MERIDIAN
Practice Address - Street 2:5
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3701
Practice Address - Country:US
Practice Address - Phone:253-864-0310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00008497122300000X
CA26856122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist