Provider Demographics
NPI:1770179061
Name:BRENTON E GLASSELL DDS MDS PLLC
Entity type:Organization
Organization Name:BRENTON E GLASSELL DDS MDS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRENTON
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MDS
Authorized Official - Phone:901-767-7370
Mailing Address - Street 1:5866 RIDGE BEND RD STE 1
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9477
Mailing Address - Country:US
Mailing Address - Phone:901-767-7370
Mailing Address - Fax:
Practice Address - Street 1:5866 RIDGE BEND RD STE 1
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9477
Practice Address - Country:US
Practice Address - Phone:901-767-7370
Practice Address - Fax:901-685-7854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-21
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN197586608Medicaid