Provider Demographics
NPI:1275696114
Name:DEAN, GLEN ROYDEN (DDS MS)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:ROYDEN
Last Name:DEAN
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2552 F RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-1422
Mailing Address - Country:US
Mailing Address - Phone:970-241-1313
Mailing Address - Fax:970-241-5202
Practice Address - Street 1:2552 F RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1422
Practice Address - Country:US
Practice Address - Phone:970-241-1313
Practice Address - Fax:970-241-5202
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1044231223P0221X
UT13565399221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02044238Medicaid
AD8713807OtherDRUG ENFORCEMENT ADMIN US