Provider Demographics
NPI:1386774057
Name:ALLEN, JEREMY W (DMD)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:W
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 W 5TH ST
Mailing Address - Street 2:SUITE 114
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-2417
Mailing Address - Country:US
Mailing Address - Phone:606-330-0330
Mailing Address - Fax:606-877-8836
Practice Address - Street 1:908 W 5TH ST
Practice Address - Street 2:SUITE 114
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-2417
Practice Address - Country:US
Practice Address - Phone:606-330-0330
Practice Address - Fax:606-877-8836
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY83651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60004306Medicaid