Provider Demographics
NPI:1598881211
Name:EDENS, GLENN R (DMD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:EDENS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:GLENN
Other - Middle Name:R,
Other - Last Name:EDENS DMD PA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:104 FRANKLIN SQUARE WAY
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-3715
Mailing Address - Country:US
Mailing Address - Phone:864-859-7288
Mailing Address - Fax:864-859-8100
Practice Address - Street 1:104 FRANKLIN SQUARE WAY
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642-3715
Practice Address - Country:US
Practice Address - Phone:864-859-7288
Practice Address - Fax:864-859-8100
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30-31041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC61906OtherUNITED CONCORDIA