Provider Demographics
NPI:1144769837
Name:MARY DISA ALLEN, DDS, PC
Entity Type:Organization
Organization Name:MARY DISA ALLEN, DDS, PC
Other - Org Name:ALLEN FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY DISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-998-7843
Mailing Address - Street 1:6232 PETERS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-4026
Mailing Address - Country:US
Mailing Address - Phone:540-362-3846
Mailing Address - Fax:
Practice Address - Street 1:6232 PETERS CREEK RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-4026
Practice Address - Country:US
Practice Address - Phone:540-362-3846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414341122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty