MEDICARE: DR. ROOSEVELT ALLEN DDS

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	122300000X	Dentist	LNO 4138	AL
2	1223G0001X	General Practice Dentistry		DE

General Provider Information

NPI Number	:	1619947868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROOSEVELT ALLEN DDS

Provider Business Mailing Address
First Line	:	13857 E CANYON FAIRWAY TRL
Second Line	:
City	:	VAIL
State	:	AZ
Zip	:	85641-6464
Country	:	US
Telephone Number	:	757-876-3082
Fax Number	:

Provider Business Practice Location Address
First Line	:	4175 S ALAMO AVE
Second Line	:
City	:	DAVIS MONTHAN A F B
State	:	AZ
Zip	:	85707-6097
Country	:	US
Telephone Number	:	520-228-2654
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	09/11/2025

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