Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-184236 | OR |
NPI | 1790844041 |
---|---|
Provider Name | Gary W Vollan |
First Address | Basin, WY 82410-0332 |
Second Address | Basin, WY 82410-0332 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/12/2006 |
Last Update Date | 08/07/2007 |