Provider Demographics
NPI:1780039503
Name:ALLEN, KATHERINE GRACE (RDH)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:GRACE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 PEMBROKE LN
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-5924
Mailing Address - Country:US
Mailing Address - Phone:248-978-6840
Mailing Address - Fax:
Practice Address - Street 1:1322 PEMBROKE LN
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-5924
Practice Address - Country:US
Practice Address - Phone:248-978-6840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902011809124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist