Provider Demographics
NPI:1437376068
Name:ALLEN, ANDON DAN (LD)
Entity type:Individual
Prefix:
First Name:ANDON
Middle Name:DAN
Last Name:ALLEN
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5527 6TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:TULALIP
Mailing Address - State:WA
Mailing Address - Zip Code:98271-6531
Mailing Address - Country:US
Mailing Address - Phone:360-657-3315
Mailing Address - Fax:425-670-0491
Practice Address - Street 1:6226 196TH ST SW
Practice Address - Street 2:2B
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-5959
Practice Address - Country:US
Practice Address - Phone:425-670-8670
Practice Address - Fax:425-670-0491
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00000017122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5038724Medicaid