Provider Demographics
NPI:1033201397
Name:GANNON, OLIVIA NICOLE (DDS)
Entity Type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:NICOLE
Last Name:GANNON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 PRINCETON ROAD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601
Mailing Address - Country:US
Mailing Address - Phone:423-975-2200
Mailing Address - Fax:423-975-2210
Practice Address - Street 1:219 PRINCETON ROAD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601
Practice Address - Country:US
Practice Address - Phone:423-975-2200
Practice Address - Fax:423-975-2210
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014115371223G0001X
TNDS95461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9183867OtherDORAL