Provider Demographics
NPI:1740480029
Name:ALLEN, MICHAEL D (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:ALLEN
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 1:363 E VIA PUENTE DE LA LLUVIA
Mailing Address - Street 2:
Mailing Address - City:SAHUARITA
Mailing Address - State:AZ
Mailing Address - Zip Code:85629-8887
Mailing Address - Country:US
Mailing Address - Phone:520-829-7776
Mailing Address - Fax:
Practice Address - Street 1:1852 N MASTICK WAY
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-1063
Practice Address - Country:US
Practice Address - Phone:520-375-5032
Practice Address - Fax:520-761-2159
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD73281223D0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ227533Medicaid