Provider Demographics
NPI:1699204057
Name:JON ERIK GLENN DDS A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JON ERIK GLENN DDS A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-644-0071
Mailing Address - Street 1:400 NEWPORT CENTER DR STE 607
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7625
Mailing Address - Country:US
Mailing Address - Phone:949-644-0071
Mailing Address - Fax:949-717-0685
Practice Address - Street 1:400 NEWPORT CENTER DR.
Practice Address - Street 2:SUITE 607
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7625
Practice Address - Country:US
Practice Address - Phone:949-644-0071
Practice Address - Fax:949-717-0685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty