Provider Demographics
NPI:1386865749
Name:HOM, GLENN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:J
Last Name:HOM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4410 30TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4231
Mailing Address - Country:US
Mailing Address - Phone:619-283-2270
Mailing Address - Fax:619-283-2257
Practice Address - Street 1:4410 30TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-4231
Practice Address - Country:US
Practice Address - Phone:619-283-2270
Practice Address - Fax:619-283-2257
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA301881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice