MEDICARE: DR. GREGORY GLAVAN 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	D10572	MN

General Provider Information

NPI Number	:	1255369195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY GLAVAN DDS

Provider Business Mailing Address
First Line	:	PO BOX 664
Second Line	:
City	:	HOWARD LAKE
State	:	MN
Zip	:	55349-0664
Country	:	US
Telephone Number	:	320-543-2233
Fax Number	:	320-543-2233

Provider Business Practice Location Address
First Line	:	612 8TH AVE
Second Line	:
City	:	HOWARD LAKE
State	:	MN
Zip	:	55349-0664
Country	:	US
Telephone Number	:	320-543-2233
Fax Number	:	320-543-2233

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/09/2007

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