Provider Demographics
NPI:1548567050
Name:BALKINS, GLENN DEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:DEE
Last Name:BALKINS
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 1:2222 NW LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-2503
Mailing Address - Country:US
Mailing Address - Phone:541-754-4017
Mailing Address - Fax:541-758-3384
Practice Address - Street 1:2222 NW LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-2503
Practice Address - Country:US
Practice Address - Phone:541-754-4017
Practice Address - Fax:541-758-3384
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD65701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice