Provider Demographics
NPI:1720056724
Name:PALLEN, RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:PALLEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3443 MEDINA RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-5965
Mailing Address - Country:US
Mailing Address - Phone:330-722-7060
Mailing Address - Fax:
Practice Address - Street 1:3443 MEDINA RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-5965
Practice Address - Country:US
Practice Address - Phone:330-722-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0168371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0535362Medicaid