MEDICARE: GLEN CONRAD HORNBUCKLE DDS MS FACD

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	1223P0300X	Periodontics	3816	OK

General Provider Information

NPI Number	:	1487711081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLEN CONRAD HORNBUCKLE DDS MS FACD

Provider Business Mailing Address
First Line	:	8203 S WALKER AVE
Second Line	:
City	:	OKLA CITY
State	:	OK
Zip	:	73139-9451
Country	:	US
Telephone Number	:	405-636-1411
Fax Number	:	405-636-1197

Provider Business Practice Location Address
First Line	:	8203 S WALKER AVE
Second Line	:
City	:	OKLA CITY
State	:	OK
Zip	:	73139-9451
Country	:	US
Telephone Number	:	405-636-1411
Fax Number	:	405-636-1197

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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