Provider Demographics
NPI:1265850721
Name:STANISLAUS, GLENN R (DMD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:STANISLAUS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-1501
Mailing Address - Country:US
Mailing Address - Phone:718-477-5588
Mailing Address - Fax:718-477-5550
Practice Address - Street 1:1003 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-1501
Practice Address - Country:US
Practice Address - Phone:718-477-5588
Practice Address - Fax:718-477-5550
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0424921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist