Provider Demographics
NPI:1225091150
Name:GLINEBURG, ROBERT WALLACE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WALLACE
Last Name:GLINEBURG
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 1:1849 PINEHURST AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1336
Mailing Address - Country:US
Mailing Address - Phone:651-698-3937
Mailing Address - Fax:
Practice Address - Street 1:1630 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 104
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3887
Practice Address - Country:US
Practice Address - Phone:651-646-9474
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN82571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery