Provider Demographics
NPI:1750471868
Name:ALLEN, JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
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:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:FARWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48622-0309
Mailing Address - Country:US
Mailing Address - Phone:989-588-4121
Mailing Address - Fax:989-588-3191
Practice Address - Street 1:301 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FARWELL
Practice Address - State:MI
Practice Address - Zip Code:48622-8753
Practice Address - Country:US
Practice Address - Phone:989-588-4121
Practice Address - Fax:989-588-3191
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID800279OtherBLUE CROSS BLUE SHIELD