Healthcare Provider Details

I. General information

NPI: 1245347897
Provider Name (Legal Business Name): BRANDON IRA ALLEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 OXFORD DR
GEORGETOWN KY
40324-9266
US

IV. Provider business mailing address

PO BOX 437169
LOUISVILLE KY
40253-7169
US

V. Phone/Fax

Practice location:
  • Phone: 502-863-0880
  • Fax: 502-867-7363
Mailing address:
  • Phone: 502-863-0880
  • Fax: 502-867-7363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8056
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8056
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: