Provider Demographics
NPI:1710112321
Name:GLENN, NATHAN CORY (DDS)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:CORY
Last Name:GLENN
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 1:215 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37398-1739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37398-1739
Practice Address - Country:US
Practice Address - Phone:931-967-1933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN89841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice