Provider Demographics
NPI:1821121914
Name:LEE, GLENN W (DDS)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:W
Last Name:LEE
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 1:1620 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-5114
Mailing Address - Country:US
Mailing Address - Phone:408-264-3911
Mailing Address - Fax:408-264-1712
Practice Address - Street 1:1620 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-5114
Practice Address - Country:US
Practice Address - Phone:408-264-3911
Practice Address - Fax:408-264-1712
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD017310122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA942597770OtherIRS NUMBER