Provider Demographics
NPI:1598395733
Name:ALLEN, CARISSA LEE-COSSEL (RDH)
Entity Type:Individual
Prefix:MRS
First Name:CARISSA
Middle Name:LEE-COSSEL
Last Name:ALLEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:MT
Mailing Address - Zip Code:59725-7104
Mailing Address - Country:US
Mailing Address - Phone:406-925-0965
Mailing Address - Fax:
Practice Address - Street 1:465 TAYLOR DR
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-7104
Practice Address - Country:US
Practice Address - Phone:406-925-0965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1306124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist