Provider Demographics
NPI:1104032259
Name:MIYAMOTO, GLENN YUTAKA (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:YUTAKA
Last Name:MIYAMOTO
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 1:451 HUNGERFORD DR
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-4176
Mailing Address - Country:US
Mailing Address - Phone:301-610-7379
Mailing Address - Fax:301-610-7704
Practice Address - Street 1:451 HUNGERFORD DR
Practice Address - Street 2:SUITE 500
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-4176
Practice Address - Country:US
Practice Address - Phone:301-610-7379
Practice Address - Fax:301-610-7704
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06011122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist