Provider Demographics
NPI:1881782738
Name:GLESNE, MARK EVAN (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EVAN
Last Name:GLESNE
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 1:3307 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-3307
Mailing Address - Country:US
Mailing Address - Phone:309-347-3066
Mailing Address - Fax:309-347-2853
Practice Address - Street 1:3307 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-3307
Practice Address - Country:US
Practice Address - Phone:309-347-3066
Practice Address - Fax:309-347-2853
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA19161541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice