Provider Demographics
NPI:1760609275
Name:GLENN J. MARIE, DDS, PC
Entity Type:Organization
Organization Name:GLENN J. MARIE, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-317-8524
Mailing Address - Street 1:PO BOX 4038
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-4038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:739 WOODROW RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-2221
Practice Address - Country:US
Practice Address - Phone:718-317-8524
Practice Address - Fax:718-984-6644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0409581223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty