Provider Demographics
NPI:1457498545
Name:KIRKPATRICK, GLEN EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:EDWARD
Last Name:KIRKPATRICK
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 1:2208 ROUNDROCK TRL
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-3136
Mailing Address - Country:US
Mailing Address - Phone:972-769-2818
Mailing Address - Fax:
Practice Address - Street 1:1609 L AVE
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-6123
Practice Address - Country:US
Practice Address - Phone:972-423-4670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX160661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice