Provider Demographics
NPI:1760863286
Name:VANALLEN, GANNON TOLMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GANNON
Middle Name:TOLMAN
Last Name:VANALLEN
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 1:674 BLVD DE FRANCE
Mailing Address - Street 2:BUILDING #674
Mailing Address - City:PARRIS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29905
Mailing Address - Country:US
Mailing Address - Phone:843-228-3500
Mailing Address - Fax:
Practice Address - Street 1:674 BLVD DE FRANCE
Practice Address - Street 2:BUILDING #674
Practice Address - City:PARRIS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29905
Practice Address - Country:US
Practice Address - Phone:843-228-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10046122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10046OtherBOARD OF DENTISTRY LICENSE NUMBER