Provider Demographics
NPI:1265618243
Name:GLENDALE FAMILY DENTISTRY, PLLC
Entity type:Organization
Organization Name:GLENDALE FAMILY DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BUI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:623-930-0060
Mailing Address - Street 1:7448 W GLENDALE AVE
Mailing Address - Street 2:STE. 126
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85303-2575
Mailing Address - Country:US
Mailing Address - Phone:623-930-0060
Mailing Address - Fax:623-930-0667
Practice Address - Street 1:7448 W GLENDALE AVE
Practice Address - Street 2:STE. 126
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-2575
Practice Address - Country:US
Practice Address - Phone:623-930-0060
Practice Address - Fax:623-930-0667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-21
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD6675122300000X
AZD6674122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty