Provider Demographics
NPI:1033461660
Name:JAMES CANNON ALLEN DDS PC
Entity Type:Organization
Organization Name:JAMES CANNON ALLEN DDS PC
Other - Org Name:ROCKHOUSE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CANNON
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-356-5600
Mailing Address - Street 1:106 E 1ST NORTH
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440
Mailing Address - Country:US
Mailing Address - Phone:208-356-5600
Mailing Address - Fax:208-419-0202
Practice Address - Street 1:106 E 1ST NORTH
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-356-5600
Practice Address - Fax:208-419-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-36341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID9201769Medicaid