Provider Demographics
NPI:1093798985
Name:THOMASON, GLENN GEORGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:GEORGE
Last Name:THOMASON
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 616
Mailing Address - Street 2:
Mailing Address - City:CHAMA
Mailing Address - State:NM
Mailing Address - Zip Code:87520-0616
Mailing Address - Country:US
Mailing Address - Phone:505-756-2345
Mailing Address - Fax:
Practice Address - Street 1:U.S. HWY 84 N, CR 324, #14
Practice Address - Street 2:
Practice Address - City:TIERRA AMARILLA
Practice Address - State:NM
Practice Address - Zip Code:87576
Practice Address - Country:US
Practice Address - Phone:505-588-7289
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD-2075122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist