Provider Demographics
NPI:1578663852
Name:GLENN D BALKINS DMD PC
Entity Type:Organization
Organization Name:GLENN D BALKINS DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:BALKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-754-4017
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6570122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR=========OtherFED TAX ID NUMBER