Provider Demographics
NPI:1356124564
Name:ALLEN, KELLY MOPANGGA (DMD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MOPANGGA
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26125 WILDFLOWER CIR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-9678
Mailing Address - Country:US
Mailing Address - Phone:907-782-9002
Mailing Address - Fax:
Practice Address - Street 1:4000 OLD SEWARD HWY STE 200
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-6068
Practice Address - Country:US
Practice Address - Phone:907-561-3639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2101331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice