Provider Demographics
NPI:1649854878
Name:GLENN, KENNETH (DDS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GLENN
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 WEYBURN DR APT A723
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-2832
Mailing Address - Country:US
Mailing Address - Phone:706-831-4341
Mailing Address - Fax:
Practice Address - Street 1:3750 ROHNERVILLE RD
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3118
Practice Address - Country:US
Practice Address - Phone:707-725-6101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1094631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program