MEDICARE: DR. ELLEN JULIENNE GLYNN DDS MDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	41258	CA

General Provider Information

NPI Number	:	1023182698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLEN JULIENNE GLYNN DDS MDS

Provider Business Mailing Address
First Line	:	655 CAMINO DE LOS MARES STE 119
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92673-2809
Country	:	US
Telephone Number	:	949-488-0600
Fax Number	:

Provider Business Practice Location Address
First Line	:	655 CAMINO DE LOS MARES STE 119
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92673-2809
Country	:	US
Telephone Number	:	949-488-0600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	03/22/2026

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