Provider Demographics
NPI:1255495958
Name:HULTSTRAND, GLENN ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ALLEN
Last Name:HULTSTRAND
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 1:8120 PENN AVE SO
Mailing Address - Street 2:STE 115
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1326
Mailing Address - Country:US
Mailing Address - Phone:952-746-8188
Mailing Address - Fax:
Practice Address - Street 1:8120 PENN AVE SO
Practice Address - Street 2:STE 115
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1326
Practice Address - Country:US
Practice Address - Phone:952-746-8188
Practice Address - Fax:952-746-4865
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9349122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist