Provider Demographics
NPI:1659114387
Name:JOU, GLENN (DDS)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:JOU
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 1:1031 W 34TH ST STE 401
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-3603
Mailing Address - Country:US
Mailing Address - Phone:213-740-2012
Mailing Address - Fax:
Practice Address - Street 1:1031 W 34TH ST STE 401
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-3603
Practice Address - Country:US
Practice Address - Phone:213-740-2012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP3171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty