Provider Demographics
NPI:1710480876
Name:GANNON, NELLIE PATRICIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:NELLIE
Middle Name:PATRICIA
Last Name:GANNON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 HEREFORD ST APT 2F
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-2514
Mailing Address - Country:US
Mailing Address - Phone:708-254-4160
Mailing Address - Fax:
Practice Address - Street 1:850 HARRISON AVE FL 6
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4001
Practice Address - Country:US
Practice Address - Phone:617-414-4837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0318421223G0001X
MADN18597991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice