Provider Demographics
NPI:1659595528
Name:GLEN, JEFFREY DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:GLEN
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 1:5224 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3712
Mailing Address - Country:US
Mailing Address - Phone:218-483-7174
Mailing Address - Fax:215-483-6039
Practice Address - Street 1:5224 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19128-3712
Practice Address - Country:US
Practice Address - Phone:215-483-7174
Practice Address - Fax:215-483-6039
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025753L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice