Provider Demographics
NPI:1356459192
Name:TUELLER, GLEN A (DDS INC)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:A
Last Name:TUELLER
Suffix:
Gender:M
Credentials:DDS INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 WATT AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821
Mailing Address - Country:US
Mailing Address - Phone:916-488-7900
Mailing Address - Fax:916-488-7901
Practice Address - Street 1:3311 WATT AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821
Practice Address - Country:US
Practice Address - Phone:916-488-7900
Practice Address - Fax:916-488-7901
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23051122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist