Provider Demographics
NPI:1154479699
Name:MARTIN, GLENN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:A
Last Name:MARTIN
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 1:28401 BRADLEY RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-3040
Mailing Address - Country:US
Mailing Address - Phone:951-679-5384
Mailing Address - Fax:951-679-3640
Practice Address - Street 1:28401 BRADLEY RD
Practice Address - Street 2:SUITE D
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-3040
Practice Address - Country:US
Practice Address - Phone:951-679-5384
Practice Address - Fax:951-679-3640
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA771450OtherUNITED CONCORDIA PROVIDER