Healthcare Provider Details

I. General information

NPI: 1427254200
Provider Name (Legal Business Name): JOHN WILTON ALLEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 S MAIN ST
DAVIDSON NC
28036-8006
US

IV. Provider business mailing address

460 S MAIN ST P.O. BOX 159
DAVIDSON NC
28036-8006
US

V. Phone/Fax

Practice location:
  • Phone: 704-892-0655
  • Fax: 704-892-0559
Mailing address:
  • Phone: 704-892-0655
  • Fax: 704-892-0559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6790
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier799005Y
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: