Provider Demographics
NPI:1508162629
Name:JEREMY W. ALLEN DMD
Entity Type:Organization
Organization Name:JEREMY W. ALLEN DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:W
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-231-0594
Mailing Address - Street 1:908 W 5TH ST
Mailing Address - Street 2:SUITE 114
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-2417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:908 W 5TH ST
Practice Address - Street 2:SUITE 114
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-2417
Practice Address - Country:US
Practice Address - Phone:606-231-0594
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-07
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8365122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60004306Medicaid