Provider Demographics
NPI:1821290081
Name:GALLIMORE, GLEN ALEXANDER (DDS)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:ALEXANDER
Last Name:GALLIMORE
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 1:8204 VIOLET MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-7607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3455 CLIFF SHADOWS PKWY
Practice Address - Street 2:SUITE 130
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-1062
Practice Address - Country:US
Practice Address - Phone:702-839-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV30501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice