Provider Demographics
NPI:1790936441
Name:AKUTAGAWA, GLENN Y (DDS)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:Y
Last Name:AKUTAGAWA
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 1:121 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4608
Mailing Address - Country:US
Mailing Address - Phone:209-823-1777
Mailing Address - Fax:209-823-1778
Practice Address - Street 1:121 E NORTH ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4608
Practice Address - Country:US
Practice Address - Phone:209-823-1777
Practice Address - Fax:209-823-1778
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA284191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice