Provider Demographics
NPI:1922236405
Name:RICHEY, GLENN URBAN (DDS)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:URBAN
Last Name:RICHEY
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:PO BOX 1009
Mailing Address - Street 2:
Mailing Address - City:OROFINO
Mailing Address - State:ID
Mailing Address - Zip Code:83544-1009
Mailing Address - Country:US
Mailing Address - Phone:208-476-4413
Mailing Address - Fax:208-476-4413
Practice Address - Street 1:13826 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-9117
Practice Address - Country:US
Practice Address - Phone:208-476-4413
Practice Address - Fax:208-476-4413
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID11181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice