Provider Demographics
NPI:1790882702
Name:PETRICK, GLEN FRANK (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:FRANK
Last Name:PETRICK
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Gender:M
Credentials:DDS MS
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Mailing Address - Street 1:4724 SWEETWATER BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-3150
Mailing Address - Country:US
Mailing Address - Phone:281-313-8890
Mailing Address - Fax:281-313-8895
Practice Address - Street 1:4724 SWEETWATER BOULEVARD
Practice Address - Street 2:SUITE 103
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-3150
Practice Address - Country:US
Practice Address - Phone:281-313-8890
Practice Address - Fax:281-313-8895
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
TX95341223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics