MEDICARE: DR. GLENN L PAULK DDD, MS

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	1223E0200X	Endodontics	DN11336	FL

General Provider Information

NPI Number	:	1437209095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN L PAULK DDD, MS

Provider Business Mailing Address
First Line	:	430 N MILLS AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-5746
Country	:	US
Telephone Number	:	407-843-8180
Fax Number	:	407-843-8924

Provider Business Practice Location Address
First Line	:	430 N MILLS AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-5746
Country	:	US
Telephone Number	:	407-843-8180
Fax Number	:	407-843-8924

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

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	07/08/2007

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