Provider Demographics
NPI:1649684697
Name:LOSASSO, GLENN (DDS)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:LOSASSO
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 1:2020 HIGHWAY A1A
Mailing Address - Street 2:SUITE 105
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-3581
Mailing Address - Country:US
Mailing Address - Phone:321-777-8225
Mailing Address - Fax:
Practice Address - Street 1:2020 HIGHWAY A1A
Practice Address - Street 2:SUITE 105
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-3581
Practice Address - Country:US
Practice Address - Phone:321-777-8225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN10790122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist