Provider Demographics
NPI:1699008797
Name:GALLAHER, THOMAS BLAINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BLAINE
Last Name:GALLAHER
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 1:1602 GRANDIN RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-2308
Mailing Address - Country:US
Mailing Address - Phone:540-344-9361
Mailing Address - Fax:540-344-9377
Practice Address - Street 1:1602 GRANDIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-2308
Practice Address - Country:US
Practice Address - Phone:540-344-9361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014134651223G0001X
HIDT-23911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty