Provider Demographics
NPI:1942793104
Name:GLENN, ELLIOTT DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:DANIEL
Last Name:GLENN
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 1:10401 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1255
Mailing Address - Country:US
Mailing Address - Phone:414-546-1900
Mailing Address - Fax:414-546-1901
Practice Address - Street 1:10401 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-1255
Practice Address - Country:US
Practice Address - Phone:414-546-1900
Practice Address - Fax:414-546-1901
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-098731223E0200X
IARES-30529390200000X
WI1002265151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program