Provider Demographics
NPI:1831202712
Name:GAVIN, GLENN R (DDS)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:GAVIN
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 1:6015 HILLCREST CT
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-1778
Mailing Address - Country:US
Mailing Address - Phone:630-852-6451
Mailing Address - Fax:630-545-9155
Practice Address - Street 1:586 DUANE ST STE 101
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4639
Practice Address - Country:US
Practice Address - Phone:630-545-0151
Practice Address - Fax:630-545-9155
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice