Provider Demographics
NPI:1649543190
Name:GLENN H GLASS DMD MS PC
Entity type:Organization
Organization Name:GLENN H GLASS DMD MS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:H
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-626-7770
Mailing Address - Street 1:PO BOX 2465
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-2465
Mailing Address - Country:US
Mailing Address - Phone:251-626-7770
Mailing Address - Fax:251-626-7464
Practice Address - Street 1:1303 MAIN ST
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-4422
Practice Address - Country:US
Practice Address - Phone:251-626-7770
Practice Address - Fax:251-626-7464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL50461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty