Provider Demographics
NPI:1790844041
Name:VOLLAN, GARY W
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:VOLLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 332
Mailing Address - Street 2:502 S. 4TH
Mailing Address - City:BASIN
Mailing Address - State:WY
Mailing Address - Zip Code:82410-0332
Mailing Address - Country:US
Mailing Address - Phone:307-568-2047
Mailing Address - Fax:
Practice Address - Street 1:502 SOUTH 4TH
Practice Address - Street 2:
Practice Address - City:BASIN
Practice Address - State:WY
Practice Address - Zip Code:82410-0332
Practice Address - Country:US
Practice Address - Phone:307-568-2047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-184236122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist