Provider Demographics
NPI:1760739379
Name:ALLEN, BRANDICE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRANDICE
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
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 93542
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30377-0542
Mailing Address - Country:US
Mailing Address - Phone:314-276-2984
Mailing Address - Fax:
Practice Address - Street 1:2090 DUNWOODY CLUB DR
Practice Address - Street 2:SUITE 105
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30350-5434
Practice Address - Country:US
Practice Address - Phone:314-276-2984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9551122300000X
GADN 0148981223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN014898OtherGEORGIA DENTAL LICENSE