Provider Demographics
NPI:1417020017
Name:LEPOR, GLENN I (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:I
Last Name:LEPOR
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 1:3909 SILVER LAKE RD NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-4352
Mailing Address - Country:US
Mailing Address - Phone:612-789-3573
Mailing Address - Fax:612-789-9669
Practice Address - Street 1:3909 SILVER LAKE RD NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-4352
Practice Address - Country:US
Practice Address - Phone:612-789-3573
Practice Address - Fax:612-789-9669
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND106501223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics