Provider Demographics
NPI:1548461809
Name:METCALF, ALLEN MAX (DDS)
Entity type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:MAX
Last Name:METCALF
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:UMC SCHOOL OF DENTISTRY
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6030
Mailing Address - Fax:601-984-6039
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:UNIVERSITY DENTISTS, PLLC
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-6185
Practice Address - Fax:601-984-6187
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2497-89122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS66342Medicaid