Provider Demographics
NPI:1659403830
Name:DEWEIRDT, GLENN LOUIS JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:LOUIS
Last Name:DEWEIRDT
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:7409 WOODRIDGE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-2249
Mailing Address - Country:US
Mailing Address - Phone:630-810-1199
Mailing Address - Fax:630-810-9922
Practice Address - Street 1:7409 WOODRIDGE DR
Practice Address - Street 2:SUITE B
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2249
Practice Address - Country:US
Practice Address - Phone:630-810-1199
Practice Address - Fax:630-810-9922
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist