Healthcare Provider Details

I. General information

NPI: 1013038264
Provider Name (Legal Business Name): ALLEN ENDODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6605 N 19TH AVE SUITE B
PHOENIX AZ
85015-1628
US

IV. Provider business mailing address

6605 N 19TH AVE SUITE B
PHOENIX AZ
85015-1628
US

V. Phone/Fax

Practice location:
  • Phone: 602-242-4745
  • Fax: 602-246-4748
Mailing address:
  • Phone: 602-242-4745
  • Fax: 602-246-4748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4952
License Number StateAZ

VIII. Authorized Official

Name: DR. JACQUELINE SAVANNAH ALLEN
Title or Position: MANAGING MEMBER
Credential: D.D.S., M.S.
Phone: 602-242-4745