MEDICARE: ROBERT CHRISTIAAN ALLEN JR.

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	FA1804637	AZ
2	122300000X	Dentist	D011510	AZ
3	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1891426235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT CHRISTIAAN ALLEN JR.

Provider Business Mailing Address
First Line	:	4499 E JUANITA AVE
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85234-7483
Country	:	US
Telephone Number	:	480-589-5528
Fax Number	:

Provider Business Practice Location Address
First Line	:	1060 S HARRISON RD STE 110
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85748-6603
Country	:	US
Telephone Number	:	520-917-0666
Fax Number	:

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

Provider Enumeration Date	:	06/17/2022
Last Update Date	:	07/26/2022

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