Healthcare Provider Details

I. General information

NPI: 1700842549
Provider Name (Legal Business Name): MARK ALLEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 NORTH MAIN ST
HARDWICK VT
05843
US

IV. Provider business mailing address

PO BOX 388 165 SHERMAN DRIVE
ST JOHNSBURY VT
05819-0388
US

V. Phone/Fax

Practice location:
  • Phone: 802-472-2260
  • Fax:
Mailing address:
  • Phone: 802-748-9405
  • Fax: 802-748-4540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number160002025
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: