Provider Demographics
NPI:1134391659
Name:GLAZUNOV, SERGE ALEXANDER (DDS)
Entity type:Individual
Prefix:DR
First Name:SERGE
Middle Name:ALEXANDER
Last Name:GLAZUNOV
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 1:41 VIA LA BRISA
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1556
Mailing Address - Country:US
Mailing Address - Phone:415-924-5551
Mailing Address - Fax:415-924-2519
Practice Address - Street 1:1620 VALLE VISTA AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2842
Practice Address - Country:US
Practice Address - Phone:707-429-2929
Practice Address - Fax:707-429-2929
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice