Provider Demographics
NPI:1528357803
Name:ALLEN, MARK DERRICK (DDS MS)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DERRICK
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2861 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032
Mailing Address - Country:US
Mailing Address - Phone:972-772-2500
Mailing Address - Fax:972-278-1320
Practice Address - Street 1:2861 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032
Practice Address - Country:US
Practice Address - Phone:972-772-2500
Practice Address - Fax:972-278-1320
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX163211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1927816Medicaid