Provider Demographics
NPI:1881902039
Name:GLENN, JORDAN MATTHEW (DDS)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MATTHEW
Last Name:GLENN
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 1:5 COLLEGE AVE
Mailing Address - Street 2:PO BOX 347
Mailing Address - City:WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:13865-4109
Mailing Address - Country:US
Mailing Address - Phone:607-655-2141
Mailing Address - Fax:607-655-3388
Practice Address - Street 1:5 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:13865-4109
Practice Address - Country:US
Practice Address - Phone:607-655-2141
Practice Address - Fax:607-655-3388
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0552681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice