Provider Demographics
NPI:1881733426
Name:SMITH, GLENN OWEN (DDS)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:OWEN
Last Name:SMITH
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 1:609 PASEO DE LOS REYES
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-6615
Mailing Address - Country:US
Mailing Address - Phone:310-791-1136
Mailing Address - Fax:310-792-9030
Practice Address - Street 1:21320 HAWTHORNE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5668
Practice Address - Country:US
Practice Address - Phone:310-792-0049
Practice Address - Fax:310-792-9030
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADK033663122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist