Healthcare Provider Details

I. General information

NPI: 1790771871
Provider Name (Legal Business Name): GLENN ROBERT HEAD D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date: 03/24/2006
Reactivation Date: 04/04/2006

III. Provider practice location address

6 POINTE CIR
GREENVILLE SC
29615-3506
US

IV. Provider business mailing address

6 POINTE CIR
GREENVILLE SC
29615-3506
US

V. Phone/Fax

Practice location:
  • Phone: 864-233-1234
  • Fax: 864-298-8009
Mailing address:
  • Phone: 864-233-1234
  • Fax: 864-298-8009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2868
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: