Provider Demographics
NPI:1841404100
Name:MISONO, GLENN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:MICHAEL
Last Name:MISONO
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 1:4660 NATOMAS BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95658
Mailing Address - Country:US
Mailing Address - Phone:916-419-0254
Mailing Address - Fax:916-419-0284
Practice Address - Street 1:4660 NATOMAS BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95835-2224
Practice Address - Country:US
Practice Address - Phone:916-419-0254
Practice Address - Fax:916-419-0284
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA309531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice