Provider Demographics
NPI:1013151083
Name:CASTOR, GLEN M (LD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:M
Last Name:CASTOR
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4246
Mailing Address - Country:US
Mailing Address - Phone:208-466-4205
Mailing Address - Fax:
Practice Address - Street 1:306 12TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4246
Practice Address - Country:US
Practice Address - Phone:208-466-4205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD-53122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist