Provider Demographics
NPI:1760430169
Name:CASEY, GLENN ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ROBERT
Last Name:CASEY
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:LANDSTUHL DENTAL ACTIVITY CREDENTIALS OFFICE
Mailing Address - Street 2:CMR 402
Mailing Address - City:APO AE
Mailing Address - State:NY
Mailing Address - Zip Code:09180
Mailing Address - Country:US
Mailing Address - Phone:367-192-9130
Mailing Address - Fax:
Practice Address - Street 1:LANDSTUHL DENTAL ACTIVITY CREDENTIALS OFFICE
Practice Address - Street 2:CMR 402
Practice Address - City:APO AE
Practice Address - State:NY
Practice Address - Zip Code:09180
Practice Address - Country:US
Practice Address - Phone:367-192-9130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics