Provider Demographics
NPI:1184841207
Name:TISTAERT, GLEN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:A
Last Name:TISTAERT
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 1:2648 34TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3115
Mailing Address - Country:US
Mailing Address - Phone:310-394-2661
Mailing Address - Fax:310-451-8971
Practice Address - Street 1:1333 7TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1607
Practice Address - Country:US
Practice Address - Phone:310-394-2661
Practice Address - Fax:310-450-9451
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA184211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice