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General NPI Number Information
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NPI Number | 1386792828
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Entity Type | Individual
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Provider Name | GLEN JOSEPH MARSACK D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 01/08/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 998 CRESCENT LAKE RD
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City | WATERFORD
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State | MI
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Zip | 48327-2594
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Country | US
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Telephone | 248-682-9331
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Fax | 248-682-9926
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Provider Business Mailing Address
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Address Line | 998 CRESCENT LAKE RD
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City | WATERFORD
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State | MI
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Zip | 48327-2594
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Country | US
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Telephone | 248-682-9331
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Fax | 248-682-9266
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D12583
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License Number State | MI
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