Provider Demographics
NPI:1588825384
Name:GLENN, RANDAL MARK (DDS)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:MARK
Last Name:GLENN
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 1:5819 HIGHWAY 6
Mailing Address - Street 2:SUITE 230
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-4052
Mailing Address - Country:US
Mailing Address - Phone:281-499-3541
Mailing Address - Fax:281-499-3533
Practice Address - Street 1:5819 HIGHWAY 6
Practice Address - Street 2:SUITE 230
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-4052
Practice Address - Country:US
Practice Address - Phone:281-499-3541
Practice Address - Fax:281-499-3533
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12832122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist