Healthcare Provider Details

I. General information

NPI: 1194791384
Provider Name (Legal Business Name): ROBERT W. GLINEBURG, D.D.S., M.S., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 UNIVERSITY AVENUE WEST SUITE 104
ST PAUL MN
55104-3888
US

IV. Provider business mailing address

1630 UNIVERSITY AVENUE WEST SUITE 104
ST PAUL MN
55104-3888
US

V. Phone/Fax

Practice location:
  • Phone: 651-646-9474
  • Fax: 651-646-9714
Mailing address:
  • Phone: 651-646-9474
  • Fax: 651-646-9714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8257
License Number StateMN

VIII. Authorized Official

Name: DR. ROBERT W. GLINEBURG
Title or Position: PRESIDENT
Credential: DDS
Phone: 651-646-9474