Provider Demographics
NPI:1154777316
Name:ALLEN, CHAD R (DDS)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:R
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 1:190 S WHITE CHAPEL BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7307
Mailing Address - Country:US
Mailing Address - Phone:817-488-3636
Mailing Address - Fax:817-421-2372
Practice Address - Street 1:190 S WHITE CHAPEL BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-488-3636
Practice Address - Fax:817-421-2372
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX334441223E0200X
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program