Healthcare Provider Details

I. General information

NPI: 1447364914
Provider Name (Legal Business Name): GARY WAYNE ALLEN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 SW UMATILLA AVE STE 200
REDMOND OR
97756-7039
US

IV. Provider business mailing address

442 SW UMATILLA AVE
REDMOND OR
97756-7039
US

V. Phone/Fax

Practice location:
  • Phone: 541-504-3938
  • Fax: 541-504-3907
Mailing address:
  • Phone: 541-504-3938
  • Fax: 541-504-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00008439
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number4806
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401008461
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: