Provider Demographics
NPI:1295847036
Name:EDMISTON, GLENN FREDERICK (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:FREDERICK
Last Name:EDMISTON
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Gender:M
Credentials:DDS MS
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Mailing Address - Street 1:302 N HAMMES AVE
Mailing Address - Street 2:SUITE #4
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-8117
Mailing Address - Country:US
Mailing Address - Phone:815-741-0301
Mailing Address - Fax:805-741-3033
Practice Address - Street 1:302 N HAMMES AVE
Practice Address - Street 2:SUITE #4
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8117
Practice Address - Country:US
Practice Address - Phone:815-741-0301
Practice Address - Fax:805-741-3033
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery