Provider Demographics
NPI:1609835859
Name:MCMILLAN, GLEN L (DDS)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:L
Last Name:MCMILLAN
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 1:130 TWIN PEAKS DR
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-4424
Mailing Address - Country:US
Mailing Address - Phone:801-544-5615
Mailing Address - Fax:801-546-9431
Practice Address - Street 1:70 W GORDON AVE
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2569
Practice Address - Country:US
Practice Address - Phone:801-546-9400
Practice Address - Fax:801-546-9431
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1385901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice