Provider Demographics
NPI:1255757308
Name:GLENDALE MODERN DENTISTRY, LLP
Entity type:Organization
Organization Name:GLENDALE MODERN DENTISTRY, LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:623-939-2600
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:5143 WEST OLIVE AVE, SUITE 140
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302
Practice Address - Country:US
Practice Address - Phone:623-939-2600
Practice Address - Fax:623-939-2603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty