Provider Demographics
NPI:1780607408
Name:CROOKS, GLENN PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:PAUL
Last Name:CROOKS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:40 PRYOR ST SW
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3145
Mailing Address - Country:US
Mailing Address - Phone:404-522-7810
Mailing Address - Fax:404-525-9489
Practice Address - Street 1:40 PRYOR ST SW
Practice Address - Street 2:1ST FLOOR
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3145
Practice Address - Country:US
Practice Address - Phone:404-522-7810
Practice Address - Fax:404-525-9489
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA93111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00023737BMedicaid