Healthcare Provider Details

I. General information

NPI: 1265477376
Provider Name (Legal Business Name): GLENN W DUNNINGTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 BAYBERRY AVE
KENNEBUNK ME
04043-7607
US

IV. Provider business mailing address

43 BAYBERRY AVE
KENNEBUNK ME
04043-7607
US

V. Phone/Fax

Practice location:
  • Phone: 903-491-8065
  • Fax:
Mailing address:
  • Phone: 903-491-8065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberF3915
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberF3915
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number15148
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: