Provider Demographics
NPI:1134283765
Name:ALLEN, MARK S (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:ALLEN
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 1:1716 ASHLEY CIR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3366
Mailing Address - Country:US
Mailing Address - Phone:270-842-0166
Mailing Address - Fax:270-781-1055
Practice Address - Street 1:1716 ASHLEY CIR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3366
Practice Address - Country:US
Practice Address - Phone:270-842-0166
Practice Address - Fax:270-781-1055
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4550 3411223S0112X
KY4550204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64045503Medicaid
KY60045507Medicaid
KY60045507Medicaid
KY64045503Medicaid