Healthcare Provider Details

I. General information

NPI: 1053413906
Provider Name (Legal Business Name): NELSON ALLEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 06/06/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5461 MERIDIAN MARK RD STE 200
ATLANTA GA
30342-4014
US

IV. Provider business mailing address

5461 MERIDIAN MARK RD STE 200
ATLANTA GA
30342-4014
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-2072
  • Fax: 404-785-5892
Mailing address:
  • Phone: 404-785-2072
  • Fax: 404-785-5892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN013148
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: