Healthcare Provider Details

I. General information

NPI: 1093945560
Provider Name (Legal Business Name): WILLIAM R. ALLEN JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2009
Last Update Date: 06/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 ABRAHAM FLEXNER WAY SUITE 302
LOUISVILLE KY
40202-1882
US

IV. Provider business mailing address

2800 CANNONS LN STE 100
LOUISVILLE KY
40205
US

V. Phone/Fax

Practice location:
  • Phone: 502-587-7874
  • Fax: 502-587-0758
Mailing address:
  • Phone: 502-454-4885
  • Fax: 502-452-1926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8471
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number8471
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8471
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: