Provider Demographics
NPI:1700443686
Name:ALLEN, MADISON VICTORIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MADISON
Middle Name:VICTORIA
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 1:6220 N MANDELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-4012
Mailing Address - Country:US
Mailing Address - Phone:773-931-1922
Mailing Address - Fax:
Practice Address - Street 1:6420 N LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-2704
Practice Address - Country:US
Practice Address - Phone:773-594-9115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-25
Last Update Date:2019-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0320941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice