Provider Demographics
NPI:1689763914
Name:ALLEN, MARVIN L JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:L
Last Name:ALLEN
Suffix:JR
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 1:316 FIFTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701
Mailing Address - Country:US
Mailing Address - Phone:229-883-1018
Mailing Address - Fax:
Practice Address - Street 1:316 FIFTH AVENUE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701
Practice Address - Country:US
Practice Address - Phone:229-883-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA72771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA70047619DAMedicare ID - Type Unspecified
GAU16818Medicare UPIN