Healthcare Provider Details

I. General information

NPI: 1528222874
Provider Name (Legal Business Name): ROBERT WEAVER GLENN DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 A ST SUITE 105
LINCOLN NE
68510-4299
US

IV. Provider business mailing address

7001 A ST SUITE 105
LINCOLN NE
68510-4299
US

V. Phone/Fax

Practice location:
  • Phone: 402-488-5275
  • Fax: 402-483-5200
Mailing address:
  • Phone: 402-488-5275
  • Fax: 402-483-5200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4351
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: