Provider Demographics
NPI:1063443018
Name:PREZKOP, GLENN CHESTER (DMD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:CHESTER
Last Name:PREZKOP
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 1:1414 S MILLER ST STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-6962
Mailing Address - Country:US
Mailing Address - Phone:805-352-0225
Mailing Address - Fax:805-352-0227
Practice Address - Street 1:1414 S MILLER ST STE B
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-6962
Practice Address - Country:US
Practice Address - Phone:805-352-0225
Practice Address - Fax:805-352-0227
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39924122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist