Provider Demographics
NPI:1467136382
Name:GLOSSIP, TRISTIN LOGAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRISTIN
Middle Name:LOGAN
Last Name:GLOSSIP
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1764 GOLDENROD CT
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-4067
Mailing Address - Country:US
Mailing Address - Phone:513-292-3594
Mailing Address - Fax:
Practice Address - Street 1:8517 PRESTON HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-5301
Practice Address - Country:US
Practice Address - Phone:502-966-4367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY109711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice