Healthcare Provider Details

I. General information

NPI: 1730682030
Provider Name (Legal Business Name): KS ALLEN TX PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N GREENVILLE AVE STE M
ALLEN TX
75002
US

IV. Provider business mailing address

1090 NORTHCHASE PKWY SE STE 150
MARIETTA GA
30067-6407
US

V. Phone/Fax

Practice location:
  • Phone: 972-426-7798
  • Fax: 214-383-9350
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number23525
License Number StateTX

VIII. Authorized Official

Name: DR. DALE MAYFIELD
Title or Position: PRESIDENT
Credential: DMD
Phone: 770-916-5036