Provider Demographics
NPI:1336466028
Name:SMALLEY, GLENDON W III (DMD)
Entity Type:Individual
Prefix:
First Name:GLENDON
Middle Name:W
Last Name:SMALLEY
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-5245
Mailing Address - Country:US
Mailing Address - Phone:478-353-3053
Mailing Address - Fax:478-353-5311
Practice Address - Street 1:117 S CALHOUN ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021
Practice Address - Country:US
Practice Address - Phone:478-353-3053
Practice Address - Fax:478-353-5311
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-21
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0141481223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery