Provider Demographics
NPI:1437209095
Name:PAULK, GLENN L (DDD, MS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:L
Last Name:PAULK
Suffix:
Gender:M
Credentials:DDD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 N MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-5746
Mailing Address - Country:US
Mailing Address - Phone:407-843-8180
Mailing Address - Fax:407-843-8924
Practice Address - Street 1:430 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5746
Practice Address - Country:US
Practice Address - Phone:407-843-8180
Practice Address - Fax:407-843-8924
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN113361223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics