Provider Demographics
NPI:1083756217
Name:ALLISON, ROBERT ELLIS (DMD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ELLIS
Last Name:ALLISON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1210
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276
Mailing Address - Country:US
Mailing Address - Phone:270-726-2274
Mailing Address - Fax:270-726-8825
Practice Address - Street 1:248 EAST 5TH STREET
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276
Practice Address - Country:US
Practice Address - Phone:270-726-2274
Practice Address - Fax:270-726-8825
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7570122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60000494Medicaid