Provider Demographics
NPI:1073797205
Name:LEW, GLENN G (DMD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:G
Last Name:LEW
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 1:35 RENATO CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-4095
Mailing Address - Country:US
Mailing Address - Phone:650-369-0366
Mailing Address - Fax:650-369-0377
Practice Address - Street 1:35 RENATO CT
Practice Address - Street 2:SUITE A
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94061-4095
Practice Address - Country:US
Practice Address - Phone:650-369-0366
Practice Address - Fax:650-369-0377
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice