Provider Demographics
NPI:1396810289
Name:SHORT, ALLAN MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:MICHAEL
Last Name:SHORT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 MAIN STREET
Mailing Address - Street 2:SUITE 2 2ND FLOOR
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757
Mailing Address - Country:US
Mailing Address - Phone:508-473-4220
Mailing Address - Fax:508-473-1442
Practice Address - Street 1:189 MAIN STREET
Practice Address - Street 2:SUITE 2 2ND FLOOR
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757
Practice Address - Country:US
Practice Address - Phone:508-473-4220
Practice Address - Fax:508-473-1442
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX05705OtherBLUE CROSS BLUE SHIELD