Provider Demographics
NPI:1831238211
Name:WAINWRIGHT, GLEN M (DDS, PLLC)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:M
Last Name:WAINWRIGHT
Suffix:
Gender:M
Credentials:DDS, PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BEARDSLEY LANE
Mailing Address - Street 2:BLDG. A, SUITE 101
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746
Mailing Address - Country:US
Mailing Address - Phone:512-330-0255
Mailing Address - Fax:512-330-0256
Practice Address - Street 1:300 BEARDSLEY LANE
Practice Address - Street 2:BLDG. A, SUITE 101
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746
Practice Address - Country:US
Practice Address - Phone:512-330-0255
Practice Address - Fax:512-330-0256
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX189471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice