Provider Demographics
NPI:1760166946
Name:GLENN, SHELBY BLADE (DDS)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:BLADE
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 1:4613 NW KLAMM RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:MO
Mailing Address - Zip Code:64150-9750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15700 N US HIGHWAY 169 STE C-2
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:MO
Practice Address - Zip Code:64089-9183
Practice Address - Country:US
Practice Address - Phone:816-343-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023021093122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist