Provider Demographics
NPI:1942235361
Name:GLOGAS, GEOFFREY LOUIS (DDS)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:LOUIS
Last Name:GLOGAS
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 1:919 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-2354
Mailing Address - Country:US
Mailing Address - Phone:260-426-8805
Mailing Address - Fax:260-424-1028
Practice Address - Street 1:506 N LINE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-1230
Practice Address - Country:US
Practice Address - Phone:260-248-4242
Practice Address - Fax:260-248-4222
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010658A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200523980Medicaid