Healthcare Provider Details

I. General information

NPI: 1447267869
Provider Name (Legal Business Name): WILLIAM JAMES GLENOS II D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: WILLIAM JAMES GLENOS D.M.D., P.A.

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 SAINT JOHNS MEDICAL PK DR
ST AUGUSTINE FL
32086-5299
US

IV. Provider business mailing address

107 INLET DR
ST AUGUSTINE FL
32080-3812
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-6453
  • Fax:
Mailing address:
  • Phone: 904-824-4886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN8867
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: