Provider Demographics
NPI:1083728810
Name:SASSER, GLENN (DDS)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:SASSER
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:PO BOX 950
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:GA
Mailing Address - Zip Code:31305-0950
Mailing Address - Country:US
Mailing Address - Phone:912-437-6601
Mailing Address - Fax:912-437-6666
Practice Address - Street 1:304 FIRST STREET
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:GA
Practice Address - Zip Code:31305
Practice Address - Country:US
Practice Address - Phone:912-437-6601
Practice Address - Fax:912-437-6666
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0107101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00384898BMedicaid