Provider Demographics
NPI:1548234685
Name:DEZARN, ALLISON MCLANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALLISON
Middle Name:MCLANE
Last Name:DEZARN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 AMY AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212-2522
Mailing Address - Country:US
Mailing Address - Phone:502-778-0001
Mailing Address - Fax:502-776-1133
Practice Address - Street 1:234 AMY AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-2522
Practice Address - Country:US
Practice Address - Phone:502-778-0001
Practice Address - Fax:502-776-1133
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY81631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60002870Medicaid