Provider Demographics
NPI:1619947868
Name:ALLEN, ROOSEVELT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROOSEVELT
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13857 E CANYON FAIRWAY TRL
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-6464
Mailing Address - Country:US
Mailing Address - Phone:757-876-3082
Mailing Address - Fax:
Practice Address - Street 1:4175 S ALAMO AVE
Practice Address - Street 2:
Practice Address - City:DAVIS MONTHAN A F B
Practice Address - State:AZ
Practice Address - Zip Code:85707-6097
Practice Address - Country:US
Practice Address - Phone:520-228-2654
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLNO 4138122300000X
DE1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice