Provider Demographics
NPI:1801159322
Name:GREEN, GLENN (DMD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:GREEN
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 1:715 W BAILEY BOSWELL RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:TX
Mailing Address - Zip Code:76179-1279
Mailing Address - Country:US
Mailing Address - Phone:817-237-7557
Mailing Address - Fax:
Practice Address - Street 1:715 W BAILEY BOSWELL RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:TX
Practice Address - Zip Code:76179-1279
Practice Address - Country:US
Practice Address - Phone:817-237-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA628671223S0112X
TX323461223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty