Provider Demographics
NPI:1407924301
Name:GLASS, RONALD GERALD (DDS)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:GERALD
Last Name:GLASS
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:PO BOX 945
Mailing Address - Street 2:
Mailing Address - City:MANNFORD
Mailing Address - State:OK
Mailing Address - Zip Code:74044-0945
Mailing Address - Country:US
Mailing Address - Phone:918-865-2247
Mailing Address - Fax:
Practice Address - Street 1:152 COONROD AVENUE
Practice Address - Street 2:
Practice Address - City:MANNFORD
Practice Address - State:OK
Practice Address - Zip Code:74044
Practice Address - Country:US
Practice Address - Phone:918-865-2247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK48731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice