Provider Demographics
NPI:1225034598
Name:RESIDE, GLENN J (DMD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:J
Last Name:RESIDE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:521 HIGHGROVE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516
Mailing Address - Country:US
Mailing Address - Phone:919-913-8008
Mailing Address - Fax:919-966-6019
Practice Address - Street 1:UNC ORAL AND MAXILLOFACIAL SURGERY
Practice Address - Street 2:115 BRAUER HALL, CB# 7450
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-7450
Practice Address - Country:US
Practice Address - Phone:919-843-2988
Practice Address - Fax:919-966-6019
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC46781223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2428923Medicare ID - Type Unspecified
NCU98346Medicare UPIN