Provider Demographics
NPI:1407041338
Name:NOMURA, GLEN STUART (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:STUART
Last Name:NOMURA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-5218
Mailing Address - Country:US
Mailing Address - Phone:360-533-0882
Mailing Address - Fax:360-533-1314
Practice Address - Street 1:222 E 1ST ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-5218
Practice Address - Country:US
Practice Address - Phone:360-533-0882
Practice Address - Fax:360-533-1314
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009154122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist