Provider Demographics
NPI:1508835414
Name:HOUSTON, GLEN D (DDS)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:D
Last Name:HOUSTON
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 1:2701 COLTRANE PL STE 3
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6783
Mailing Address - Country:US
Mailing Address - Phone:405-715-4500
Mailing Address - Fax:
Practice Address - Street 1:2701 COLTRANE PL STE 3
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6783
Practice Address - Country:US
Practice Address - Phone:405-715-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37531223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK800522089OtherGROUP MEDICARE
OK800522089OtherGROUP MEDICARE
OKU66824Medicare UPIN
OK$$$$$$$$$PMedicare PIN
OK$$$$$$$$$RMedicare PIN