Healthcare Provider Details

I. General information

NPI: 1629169651
Provider Name (Legal Business Name): GLEN R. CIPRIANI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5519 SW H K DODGEN LOOP
TEMPLE TX
76502-7422
US

IV. Provider business mailing address

5519 SW H K DODGEN LOOP
TEMPLE TX
76502-7422
US

V. Phone/Fax

Practice location:
  • Phone: 254-778-4951
  • Fax: 254-778-4199
Mailing address:
  • Phone: 254-778-4951
  • Fax: 254-778-4199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13596
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: