Provider Demographics
NPI:1679740336
Name:POULESON, GLENN R (DMD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:POULESON
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 1:6800 MAIN ST
Mailing Address - Street 2:APEX ENDODONTICS #205
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516
Mailing Address - Country:US
Mailing Address - Phone:630-964-4499
Mailing Address - Fax:630-964-4523
Practice Address - Street 1:6800 MAIN ST
Practice Address - Street 2:APEX ENDODONTICS #205
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516
Practice Address - Country:US
Practice Address - Phone:630-964-4499
Practice Address - Fax:630-964-4523
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021-0013471223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics