Basic Information
| Provider Information | |||||||||
| NPI: | 1255757308 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLENDALE MODERN DENTISTRY, LLP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GLENDALE MODERN DENTISTRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17000 RED HILL AVE | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926145626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458890 | ||||||||
| FaxNumber: | 9494741495 | ||||||||
| Practice Location | |||||||||
| Address1: | 5143 WEST OLIVE AVE, SUITE 140 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239392600 | ||||||||
| FaxNumber: | 6239392603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2014 | ||||||||
| LastUpdateDate: | 03/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | MARISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 6239392600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.