Provider Demographics
NPI:1346380466
Name:ALLEN, DAVID LAWRENCE (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LAWRENCE
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4848 NE STALLINGS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1239
Mailing Address - Country:US
Mailing Address - Phone:936-564-5090
Mailing Address - Fax:936-564-2999
Practice Address - Street 1:4848 NE STALLINGS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1239
Practice Address - Country:US
Practice Address - Phone:936-564-5090
Practice Address - Fax:936-564-2999
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX145991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU63763Medicare UPIN