Provider Demographics
NPI:1760863286
Name:VANALLEN, GANNON TOLMAN (DDS, CERT)
Entity type:Individual
Prefix:DR
First Name:GANNON
Middle Name:TOLMAN
Last Name:VANALLEN
Suffix:
Gender:M
Credentials:DDS, CERT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3481 E SUNSET RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-6207
Mailing Address - Country:US
Mailing Address - Phone:702-830-4144
Mailing Address - Fax:
Practice Address - Street 1:3481 E SUNSET RD STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-6207
Practice Address - Country:US
Practice Address - Phone:702-830-4144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS3-372C1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10046OtherBOARD OF DENTISTRY LICENSE NUMBER