Provider Demographics
NPI:1710124946
Name:MISKA, GLEN B (DDS)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:B
Last Name:MISKA
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 1:1615 32ND ST NE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-4072
Mailing Address - Country:US
Mailing Address - Phone:319-294-2323
Mailing Address - Fax:319-395-6715
Practice Address - Street 1:1615 32ND ST NE
Practice Address - Street 2:SUITE 1
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-4072
Practice Address - Country:US
Practice Address - Phone:319-294-2323
Practice Address - Fax:319-395-6715
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA6071122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist