Provider Demographics
NPI:1700923984
Name:BUI, GLEN (DMD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:
Last Name:BUI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12568 W FLOWER ST
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-6376
Mailing Address - Country:US
Mailing Address - Phone:623-930-0060
Mailing Address - Fax:623-930-0667
Practice Address - Street 1:7448 W GLENDALE AVE
Practice Address - Street 2:SUITE 126
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-2575
Practice Address - Country:US
Practice Address - Phone:623-930-0060
Practice Address - Fax:623-930-0667
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6675122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD6675OtherAZDA