Provider Demographics
NPI:1033194956
Name:FALLO, GLEN JAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:JAY
Last Name:FALLO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 CORPORAL EVANS RD
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93944-3403
Mailing Address - Country:US
Mailing Address - Phone:831-242-5612
Mailing Address - Fax:831-242-5772
Practice Address - Street 1:423 CORPORAL EVANS RD
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93944-3403
Practice Address - Country:US
Practice Address - Phone:831-242-5612
Practice Address - Fax:831-242-5772
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY60221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice