Provider Demographics
NPI:1376665323
Name:ALLEN, BRADFORD MONCRIEF (DDS)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:MONCRIEF
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 1:13470 N 83RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4148
Mailing Address - Country:US
Mailing Address - Phone:623-412-9600
Mailing Address - Fax:623-412-9700
Practice Address - Street 1:13470 N 83RD AVE STE 100
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4148
Practice Address - Country:US
Practice Address - Phone:623-412-9600
Practice Address - Fax:623-412-9700
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice