Provider Demographics
NPI:1437198017
Name:DAVIS, GLENN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:DAVIS
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 1:3703 N KICKAPOO AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1703
Mailing Address - Country:US
Mailing Address - Phone:405-275-0640
Mailing Address - Fax:405-275-1502
Practice Address - Street 1:3703 N KICKAPOO AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1703
Practice Address - Country:US
Practice Address - Phone:405-275-0640
Practice Address - Fax:405-275-1502
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK38391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice