Provider Demographics
NPI:1255344453
Name:ALLEN, KATHIE SUE (DDS)
Entity type:Individual
Prefix:DR
First Name:KATHIE
Middle Name:SUE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:836 SUNSET LAKE BLVD
Mailing Address - Street 2:SUITE #204 LAKESIDE MEDICAL CENTER
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-7556
Mailing Address - Country:US
Mailing Address - Phone:941-492-3211
Mailing Address - Fax:941-492-3212
Practice Address - Street 1:836 SUNSET LAKE BLVD
Practice Address - Street 2:SUITE #204
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-7556
Practice Address - Country:US
Practice Address - Phone:941-492-3211
Practice Address - Fax:941-492-3212
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00136321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice