Provider Demographics
NPI:1952455073
Name:ALLEN, LESLIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
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 1:3931 HIGHWAY 78 W
Mailing Address - Street 2:STE A
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-3907
Mailing Address - Country:US
Mailing Address - Phone:770-985-1050
Mailing Address - Fax:
Practice Address - Street 1:3931 HIGHWAY 78 W
Practice Address - Street 2:STE A
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-3907
Practice Address - Country:US
Practice Address - Phone:770-985-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300190141223G0001X
GADN012334122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH269-3732Medicaid