Healthcare Provider Details

I. General information

NPI: 1770571291
Provider Name (Legal Business Name): JEFFREY B ALLAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 MAIN ST
TEWKSBURY MA
01876-2083
US

IV. Provider business mailing address

1445 MAIN ST
TEWKSBURY MA
01876-2083
US

V. Phone/Fax

Practice location:
  • Phone: 978-851-4764
  • Fax: 978-851-8673
Mailing address:
  • Phone: 978-851-4764
  • Fax: 978-851-8673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13451
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: