Provider Demographics
NPI:1427254200
Name:ALLEN, JOHN WILTON (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILTON
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 1:460 S MAIN ST
Mailing Address - Street 2:P.O. BOX 159
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-8006
Mailing Address - Country:US
Mailing Address - Phone:704-892-0655
Mailing Address - Fax:704-892-0559
Practice Address - Street 1:460 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-8006
Practice Address - Country:US
Practice Address - Phone:704-892-0655
Practice Address - Fax:704-892-0559
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC67901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC799005YMedicaid