MEDICARE: DR. MARCELLUS GLADNEY D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	DD1966	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659362333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARCELLUS GLADNEY D.M.D.

Provider Business Mailing Address
First Line	:	1905 BLUE SPRUCE DR
Second Line	:
City	:	GRANTS
State	:	NM
Zip	:	87020-4213
Country	:	US
Telephone Number	:	505-876-1065
Fax Number	:	505-876-4036

Provider Business Practice Location Address
First Line	:	1209 BONITA ST
Second Line	:
City	:	GRANTS
State	:	NM
Zip	:	87020-2103
Country	:	US
Telephone Number	:	505-876-4034
Fax Number	:	505-876-4036

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	07/09/2007

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