Provider Demographics
NPI:1659362333
Name:GLADNEY, MARCELLUS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARCELLUS
Middle Name:
Last Name:GLADNEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 BLUE SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-4213
Mailing Address - Country:US
Mailing Address - Phone:505-876-1065
Mailing Address - Fax:505-876-4036
Practice Address - Street 1:1209 BONITA ST
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2103
Practice Address - Country:US
Practice Address - Phone:505-876-4034
Practice Address - Fax:505-876-4036
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD19661223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ9089Medicaid
NM8615Medicaid