Provider Demographics
NPI:1912968991
Name:TERRY, GLENN L (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:L
Last Name:TERRY
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 1:356 CIELO GRANDE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-7831
Mailing Address - Country:US
Mailing Address - Phone:505-572-7302
Mailing Address - Fax:
Practice Address - Street 1:356 CIELO GRANDE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-7831
Practice Address - Country:US
Practice Address - Phone:505-572-7302
Practice Address - Fax:505-572-3634
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4953122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist