Provider Demographics
NPI:1093800039
Name:GLENN P. FRIAL, DDS, MS, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:GLENN P. FRIAL, DDS, MS, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:P
Authorized Official - Last Name:FRIAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:949-276-2105
Mailing Address - Street 1:28202 CABOT RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-1250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28202 CABOT RD
Practice Address - Street 2:SUITE 250
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-1250
Practice Address - Country:US
Practice Address - Phone:949-276-2105
Practice Address - Fax:949-276-2109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA410121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty