Provider Demographics
NPI:1245444165
Name:KORSEN, GLEN (DDS)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:KORSEN
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 1:50 ROUTE 111
Mailing Address - Street 2:SUITE 214
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3700
Mailing Address - Country:US
Mailing Address - Phone:631-265-3266
Mailing Address - Fax:631-382-7913
Practice Address - Street 1:50 ROUTE 111
Practice Address - Street 2:SUITE 214
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3700
Practice Address - Country:US
Practice Address - Phone:631-265-3266
Practice Address - Fax:631-382-7913
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY0471211223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry