Provider Demographics
NPI:1508350299
Name:ALLEN, EMILY MARIE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:MARIE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 BANTAS POINT LN
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-2306
Mailing Address - Country:US
Mailing Address - Phone:952-250-3698
Mailing Address - Fax:
Practice Address - Street 1:114 PIONEER TRL
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1167
Practice Address - Country:US
Practice Address - Phone:952-361-6855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14050122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist