Provider Demographics
NPI:1013462605
Name:ALLEN, JEDIDIAH (DDS, MS, ABGD)
Entity Type:Individual
Prefix:DR
First Name:JEDIDIAH
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DDS, MS, ABGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1838 NORMANDY DR
Mailing Address - Street 2:
Mailing Address - City:FORT LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:28310-8503
Mailing Address - Country:US
Mailing Address - Phone:910-432-4227
Mailing Address - Fax:
Practice Address - Street 1:1838 NORMANDY DR
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-5095
Practice Address - Country:US
Practice Address - Phone:910-432-4227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32184122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist