Provider Demographics
NPI:1073608410
Name:ALLEN, HEATHER (DDS)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 S. HAIRSTON ROAD
Mailing Address - Street 2:SUITE 23
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088
Mailing Address - Country:US
Mailing Address - Phone:404-294-3600
Mailing Address - Fax:404-294-9880
Practice Address - Street 1:1234 S. HAIRSTON ROAD
Practice Address - Street 2:SUITE 23
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088
Practice Address - Country:US
Practice Address - Phone:404-294-3600
Practice Address - Fax:404-294-9880
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA109821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00581215AMedicaid