Provider Demographics
NPI:1518134824
Name:WALTER E GLENN DDS INC
Entity Type:Organization
Organization Name:WALTER E GLENN DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:E
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-522-2523
Mailing Address - Street 1:13 PARK AVE WEST SUITE 517
Mailing Address - Street 2:WALTER E GLENN DDS INC
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44902
Mailing Address - Country:US
Mailing Address - Phone:419-522-2523
Mailing Address - Fax:419-522-2523
Practice Address - Street 1:13 PARK AVE WEST SUITE 517
Practice Address - Street 2:WALTER E GLENN DDS INC
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44902
Practice Address - Country:US
Practice Address - Phone:419-522-2523
Practice Address - Fax:419-522-2523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH18506122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0665034Medicaid