Healthcare Provider Details

I. General information

NPI: 1780121798
Provider Name (Legal Business Name): DR. THOMAS J. ALLEN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 S 700 E SUITE 4
SALT LAKE CITY UT
84107-2186
US

IV. Provider business mailing address

PO BOX 982902
PARK CITY UT
84098-2902
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-4352
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number9332582-9921
License Number StateUT

VIII. Authorized Official

Name: DR. THOMAS JAMES ALLEN
Title or Position: CEO
Credential: DDS
Phone: 210-602-9831