Provider Demographics
NPI:1417007337
Name:GLENN, COLBERT JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:COLBERT
Middle Name:JAY
Last Name:GLENN
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 1:5707 N CYNTHIA ST
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-1812
Mailing Address - Country:US
Mailing Address - Phone:956-605-6453
Mailing Address - Fax:
Practice Address - Street 1:710 S CAGE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-5446
Practice Address - Country:US
Practice Address - Phone:956-283-1861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14932122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist