Provider Demographics
NPI:1528181351
Name:VANCE,JR., GLENN EVERETTE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:EVERETTE
Last Name:VANCE,JR.
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 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-2203
Mailing Address - Country:US
Mailing Address - Phone:423-968-2232
Mailing Address - Fax:423-968-3601
Practice Address - Street 1:400 6TH ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-2203
Practice Address - Country:US
Practice Address - Phone:423-968-2232
Practice Address - Fax:423-968-3601
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS26221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice