Provider Demographics
NPI:1245293604
Name:WATERS, GLENN STEWART (DDS,MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:STEWART
Last Name:WATERS
Suffix:
Gender:M
Credentials:DDS,MD
Other - Prefix:DR
Other - First Name:GLENN
Other - Middle Name:STEWART
Other - Last Name:WATERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS,MD
Mailing Address - Street 1:10506 MONTGOMERY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-4487
Mailing Address - Country:US
Mailing Address - Phone:513-791-0550
Mailing Address - Fax:513-791-1517
Practice Address - Street 1:10506 MONTGOMERY RD
Practice Address - Street 2:SUITE 203
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-4487
Practice Address - Country:US
Practice Address - Phone:513-791-0550
Practice Address - Fax:513-791-1517
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300220991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHWA4164571Medicare ID - Type Unspecified
OHVO5839Medicare UPIN