Provider Demographics
NPI:1538284443
Name:BLINCOE, GLENN R (DMD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:BLINCOE
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 1:4122 SHELBYVILLE RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3242
Mailing Address - Country:US
Mailing Address - Phone:502-895-2210
Mailing Address - Fax:
Practice Address - Street 1:4122 SHELBYVILLE RD
Practice Address - Street 2:SUITE 115
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3242
Practice Address - Country:US
Practice Address - Phone:502-895-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice