MEDICARE: DR. SERGE ALEXANDER GLAZUNOV DDS

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	23504	CA

General Provider Information

NPI Number	:	1134391659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SERGE ALEXANDER GLAZUNOV DDS

Provider Business Mailing Address
First Line	:	41 VIA LA BRISA
Second Line	:
City	:	LARKSPUR
State	:	CA
Zip	:	94939-1556
Country	:	US
Telephone Number	:	415-924-5551
Fax Number	:	415-924-2519

Provider Business Practice Location Address
First Line	:	1620 VALLE VISTA AVE
Second Line	:	SUITE 150
City	:	VALLEJO
State	:	CA
Zip	:	94589-2842
Country	:	US
Telephone Number	:	707-429-2929
Fax Number	:	707-429-2929

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

Provider Enumeration Date	:	03/25/2008
Last Update Date	:	03/25/2008

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