Provider Demographics
NPI:1588007306
Name:ALLEN, MARY DISA RAULFS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY DISA
Middle Name:RAULFS
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MARY DISA
Other - Middle Name:MALLARD
Other - Last Name:RAULFS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:4051 POSTAL DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-6439
Mailing Address - Country:US
Mailing Address - Phone:540-774-0061
Mailing Address - Fax:
Practice Address - Street 1:4051 POSTAL DR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-6439
Practice Address - Country:US
Practice Address - Phone:540-774-0061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR5441223G0001X
VA04014143411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice