Provider Demographics
NPI:1780769570
Name:MAYLATH, GLEN DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:DAVID
Last Name:MAYLATH
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 1:50 W BIG BEAVER RD STE 120
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-3911
Mailing Address - Country:US
Mailing Address - Phone:248-642-5020
Mailing Address - Fax:
Practice Address - Street 1:50 W BIG BEAVER RD STE 120
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-3911
Practice Address - Country:US
Practice Address - Phone:248-642-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010147671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice