Provider Demographics
NPI:1093945560
Name:ALLEN, WILLIAM R JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:ALLEN
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
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Mailing Address - Street 1:2800 CANNONS LN
Mailing Address - Street 2:STE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205
Mailing Address - Country:US
Mailing Address - Phone:502-454-4885
Mailing Address - Fax:502-452-1926
Practice Address - Street 1:225 ABRAHAM FLEXNER WAY
Practice Address - Street 2:SUITE 302
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1882
Practice Address - Country:US
Practice Address - Phone:502-587-7874
Practice Address - Fax:502-587-0758
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-19
Last Update Date:2017-06-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY8471122300000X, 204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000770334OtherANTHEM
KY7100210290Medicaid
IN201098860Medicaid
KYP01500682OtherRAILROAD MEDICARE
KY7100210090Medicaid
KYP01500682OtherRAILROAD MEDICARE