Provider Demographics
NPI:1396724126
Name:GILLAM, JOHN NELSON (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:NELSON
Last Name:GILLAM
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 1:650 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-4101
Mailing Address - Country:US
Mailing Address - Phone:785-827-0808
Mailing Address - Fax:
Practice Address - Street 1:650 S FRONT ST
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-4101
Practice Address - Country:US
Practice Address - Phone:785-827-0808
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS57501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice