Provider Demographics
NPI:1023125002
Name:LABINE, GLENN WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:WAYNE
Last Name:LABINE
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 1:2401 S WASHINGTON
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6747
Mailing Address - Country:US
Mailing Address - Phone:701-775-0682
Mailing Address - Fax:
Practice Address - Street 1:2401 S WASHINGTON
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6747
Practice Address - Country:US
Practice Address - Phone:701-775-0682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND15351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40572Medicaid