Provider Demographics
NPI:1275592701
Name:MAKOWSKI, GLENN JOSEPH (MD DMD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:JOSEPH
Last Name:MAKOWSKI
Suffix:
Gender:M
Credentials:MD DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2125 RIM ROCK DR
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-5627
Mailing Address - Country:US
Mailing Address - Phone:817-741-2200
Mailing Address - Fax:817-741-2216
Practice Address - Street 1:4224 HERITAGE TRACE PKWY
Practice Address - Street 2:SUITE 304
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-1378
Practice Address - Country:US
Practice Address - Phone:817-741-2200
Practice Address - Fax:817-741-2216
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226011223S0112X
AR33761223S0112X
NJ22DI020308001223S0112X
AR601223S0112X
TXK8654204E00000X
ARE3009204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H60323Medicare UPIN
5M080Medicare ID - Type Unspecified