Provider Demographics
NPI:1164572939
Name:ROEDER, GLENN STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:STEPHEN
Last Name:ROEDER
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 67827
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2806
Mailing Address - Country:US
Mailing Address - Phone:310-739-5579
Mailing Address - Fax:
Practice Address - Street 1:230 N MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4261
Practice Address - Country:US
Practice Address - Phone:310-739-5579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306241223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics