Provider Demographics
NPI:1902490840
Name:KEVIN M ALLRED DDS PC
Entity Type:Organization
Organization Name:KEVIN M ALLRED DDS PC
Other - Org Name:POWELL VALLEY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLRED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-807-6632
Mailing Address - Street 1:407 3RD AVE E
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-2365
Mailing Address - Country:US
Mailing Address - Phone:276-523-0931
Mailing Address - Fax:276-523-0932
Practice Address - Street 1:407 3RD AVE E
Practice Address - Street 2:
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-2365
Practice Address - Country:US
Practice Address - Phone:276-523-0931
Practice Address - Fax:276-523-0932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-22
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1679834287OtherDENTAL