Provider Demographics
NPI:1497856488
Name:GLENN, JON ERIK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:ERIK
Last Name:GLENN
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 1:400 NEWPORT CENTER DRIVE
Mailing Address - Street 2:SUITE 607
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7625
Mailing Address - Country:US
Mailing Address - Phone:949-644-0071
Mailing Address - Fax:949-717-0685
Practice Address - Street 1:400 NEWPORT CENTER DR
Practice Address - Street 2:SUITE 607
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7625
Practice Address - Country:US
Practice Address - Phone:949-644-0071
Practice Address - Fax:949-717-0685
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA357231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice