Healthcare Provider Details

I. General information

NPI: 1609166644
Provider Name (Legal Business Name): NICHOLAS D ALLAN D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2831 E SOUTHERN AVE #215
MESA AZ
85204-5500
US

IV. Provider business mailing address

3508 FAR WEST BLVD 330
AUSTIN TX
78731-3080
US

V. Phone/Fax

Practice location:
  • Phone: 618-972-8464
  • Fax:
Mailing address:
  • Phone: 512-343-9488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number30349
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: