MEDICARE: ALLEN ENDODONTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	4952	AZ

General Provider Information

NPI Number	:	1013038264
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLEN ENDODONTICS, LLC

Provider Business Mailing Address
First Line	:	6605 N 19TH AVE
Second Line	:	SUITE B
City	:	PHOENIX
State	:	AZ
Zip	:	85015-1628
Country	:	US
Telephone Number	:	602-242-4745
Fax Number	:	602-246-4748

Provider Business Practice Location Address
First Line	:	6605 N 19TH AVE
Second Line	:	SUITE B
City	:	PHOENIX
State	:	AZ
Zip	:	85015-1628
Country	:	US
Telephone Number	:	602-242-4745
Fax Number	:	602-246-4748

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. JACQUELINE SAVANNAH ALLEN
Credential	:	D.D.S., M.S.
Telephone Number	:	602-242-4745

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	08/22/2020

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