Provider Demographics
NPI:1174753180
Name:ALLEN, GENEVIEVE L (DMD)
Entity type:Individual
Prefix:DR
First Name:GENEVIEVE
Middle Name:L
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 BROADWAY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46012-2568
Mailing Address - Country:US
Mailing Address - Phone:765-641-7930
Mailing Address - Fax:765-641-7957
Practice Address - Street 1:777 BROADWAY ST
Practice Address - Street 2:SUITE A
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46012-2568
Practice Address - Country:US
Practice Address - Phone:765-641-7930
Practice Address - Fax:765-641-7957
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011345A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist