Provider Demographics
NPI:1861818817
Name:MCDONALD, GLEN JR (DDS)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:MCDONALD
Suffix:JR
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 1:5820 MCCLELLAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36206-8466
Mailing Address - Country:US
Mailing Address - Phone:256-820-5570
Mailing Address - Fax:256-820-5322
Practice Address - Street 1:5820 MCCLELLAN BLVD
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36206-8466
Practice Address - Country:US
Practice Address - Phone:256-820-5570
Practice Address - Fax:256-820-5322
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3442122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist