Provider Demographics
NPI:1578718672
Name:GOODRICH, GLENN CHARLES (MS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:CHARLES
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34501 AURORA RD STE 305
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-3831
Mailing Address - Country:US
Mailing Address - Phone:440-248-4825
Mailing Address - Fax:440-248-5489
Practice Address - Street 1:34501 AURORA RD STE 305
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-3831
Practice Address - Country:US
Practice Address - Phone:440-248-4825
Practice Address - Fax:440-248-5489
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH115991223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics