Healthcare Provider Details

I. General information

NPI: 1902994817
Provider Name (Legal Business Name): GLENN DUKE SOSEBEE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 SHERWOOD PARK DR NE
GAINESVILLE GA
30501-3444
US

IV. Provider business mailing address

1215 SHERWOOD PARK DR NE
GAINESVILLE GA
30501-3444
US

V. Phone/Fax

Practice location:
  • Phone: 770-532-4156
  • Fax:
Mailing address:
  • Phone: 770-532-4156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN011067
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: