Provider Demographics
NPI:1689851636
Name:ALLEN, MICHAEL JAY (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAY
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 W HARVARD AVENUE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470
Mailing Address - Country:US
Mailing Address - Phone:541-440-9175
Mailing Address - Fax:541-673-1246
Practice Address - Street 1:1813 W HARVARD AVENUE
Practice Address - Street 2:SUITE 240
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470
Practice Address - Country:US
Practice Address - Phone:541-440-9175
Practice Address - Fax:541-673-1246
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD87521223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics