Provider Demographics
NPI:1740322742
Name:MCCORMICK, GLENN PAUL (DDS)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:PAUL
Last Name:MCCORMICK
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 1:400000 FREMONT BLVD
Mailing Address - Street 2:SUITEA
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538
Mailing Address - Country:US
Mailing Address - Phone:510-651-2222
Mailing Address - Fax:510-651-0332
Practice Address - Street 1:400000 FREMONT BLVD
Practice Address - Street 2:A
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2978
Practice Address - Country:US
Practice Address - Phone:510-651-2222
Practice Address - Fax:510-651-0332
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22164122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist