Healthcare Provider Details

I. General information

NPI: 1033040092
Provider Name (Legal Business Name): ELI BERTRAM ALLEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4041 PARNELL AVE
FORT WAYNE IN
46805-1413
US

IV. Provider business mailing address

1143 W RUDISILL BLVD
FORT WAYNE IN
46807-2142
US

V. Phone/Fax

Practice location:
  • Phone: 260-297-7511
  • Fax:
Mailing address:
  • Phone: 260-417-2563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12014983A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: