Provider Demographics
NPI:1457759946
Name:WRIGHT-GLENN, DESMOND
Entity Type:Individual
Prefix:
First Name:DESMOND
Middle Name:
Last Name:WRIGHT-GLENN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2566 E GRAND BLVD
Mailing Address - Street 2:APT 117
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48211-2019
Mailing Address - Country:US
Mailing Address - Phone:248-217-9416
Mailing Address - Fax:
Practice Address - Street 1:2566 E GRAND BLVD
Practice Address - Street 2:APT 117
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48211-2019
Practice Address - Country:US
Practice Address - Phone:248-217-9416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other