Provider Demographics
NPI:1518201714
Name:ALLEN, JEFFERY MARCUS (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:MARCUS
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-3700
Mailing Address - Fax:601-450-2493
Practice Address - Street 1:68 OLD AIRPORT RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8382
Practice Address - Country:US
Practice Address - Phone:601-583-4800
Practice Address - Fax:601-584-7769
Is Sole Proprietor?:No
Enumeration Date:2012-11-12
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3676-121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08822205Medicaid