Healthcare Provider Details

I. General information

NPI: 1508835414
Provider Name (Legal Business Name): GLEN D HOUSTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 COLTRANE PL STE 3
EDMOND OK
73034-6783
US

IV. Provider business mailing address

2701 COLTRANE PL STE 3
EDMOND OK
73034-6783
US

V. Phone/Fax

Practice location:
  • Phone: 405-715-4500
  • Fax:
Mailing address:
  • Phone: 405-715-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number3753
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: