Provider Demographics
NPI:1063473718
Name:FISHMAN, GLEN W (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:W
Last Name:FISHMAN
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 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5147
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:
Practice Address - Street 1:55981 E COLFAX AVE
Practice Address - Street 2:
Practice Address - City:STRASBURG
Practice Address - State:CO
Practice Address - Zip Code:80136-8014
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0142251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12978345Medicaid