Provider Demographics
NPI:1154484616
Name:GEQUILLANA, GLENN DELA LLANA (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:DELA LLANA
Last Name:GEQUILLANA
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 1:2901 W KINNICKINNIC RIVER PKWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3677
Mailing Address - Country:US
Mailing Address - Phone:414-649-3510
Mailing Address - Fax:414-385-2854
Practice Address - Street 1:2901 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3677
Practice Address - Country:US
Practice Address - Phone:414-649-3510
Practice Address - Fax:414-385-2854
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5003015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33777200Medicare ID - Type UnspecifiedMEDICARE #