Provider Demographics
NPI:1144370958
Name:ALLEN, CHARLES DAVIS JR (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DAVIS
Last Name:ALLEN
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 235
Mailing Address - Street 2:508 MCKAY ST
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-0235
Mailing Address - Country:US
Mailing Address - Phone:910-862-4334
Mailing Address - Fax:910-862-3813
Practice Address - Street 1:508 MCKAY ST.
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337-0235
Practice Address - Country:US
Practice Address - Phone:910-862-4334
Practice Address - Fax:910-862-3813
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC37621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990169Medicaid