Provider Demographics
NPI:1801353206
Name:JEFFREY W GLYNN
Entity type:Organization
Organization Name:JEFFREY W GLYNN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:GLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-843-7263
Mailing Address - Street 1:NORTH CANTON - GLYNN FAMILY DENTAL
Mailing Address - Street 2:129 EASTON ST NE
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721
Mailing Address - Country:US
Mailing Address - Phone:330-494-3400
Mailing Address - Fax:330-497-3404
Practice Address - Street 1:NORTH CANTON - GLYNN FAMILY DENTAL
Practice Address - Street 2:129 EASTON ST NE
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44721
Practice Address - Country:US
Practice Address - Phone:330-494-3400
Practice Address - Fax:330-497-3404
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFREY W GLYNN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-22
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0616695Medicaid