MEDICARE: DR. ROGER DALE GLENN D.D.S.

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	1223G0001X	General Practice Dentistry	17335	TX

General Provider Information

NPI Number	:	1053396010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER DALE GLENN D.D.S.

Provider Business Mailing Address
First Line	:	6040 OJO DE AGUA DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-7504
Country	:	US
Telephone Number	:	915-568-5001
Fax Number	:	915-568-5174

Provider Business Practice Location Address
First Line	:	128 CHAFFEE RD.
Second Line	:
City	:	FORT BLISS
State	:	TX
Zip	:	79906-3811
Country	:	US
Telephone Number	:	915-568-5001
Fax Number	:	915-568-5174

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

Provider Enumeration Date	:	12/13/2005
Last Update Date	:	07/08/2007

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