Provider Demographics
NPI:1760588016
Name:ALLEN, MARLA J
Entity Type:Individual
Prefix:DR
First Name:MARLA
Middle Name:J
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136A STAFF DRIVE
Mailing Address - Street 2:
Mailing Address - City:FT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548
Mailing Address - Country:US
Mailing Address - Phone:850-243-5668
Mailing Address - Fax:850-243-6890
Practice Address - Street 1:136A STAFF DRIVE
Practice Address - Street 2:
Practice Address - City:FT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548
Practice Address - Country:US
Practice Address - Phone:850-243-5668
Practice Address - Fax:850-243-6890
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11210122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist