Provider Demographics
NPI:1679889398
Name:GALLOWAY, TRISTAN (DDS)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:GALLOWAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 S MIDLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-8215
Mailing Address - Country:US
Mailing Address - Phone:208-250-3115
Mailing Address - Fax:
Practice Address - Street 1:3600 S MIDLAND BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-8215
Practice Address - Country:US
Practice Address - Phone:208-250-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4321122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist