Provider Demographics
NPI:1902951056
Name:DAVIS, ALLEN GLEN (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:GLEN
Last Name:DAVIS
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 1:9420 MIRA MESA BLVD STE J
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4848
Mailing Address - Country:US
Mailing Address - Phone:858-578-5002
Mailing Address - Fax:858-578-5832
Practice Address - Street 1:9420 MIRA MESA BLVD STE J
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4848
Practice Address - Country:US
Practice Address - Phone:858-578-5002
Practice Address - Fax:858-578-5832
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics