MEDICARE: R. GLENN KITASOE,DDS,INC.

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	29329	CA

General Provider Information

NPI Number	:	1689894198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	R. GLENN KITASOE,DDS,INC.

Provider Business Mailing Address
First Line	:	825 OAK GROVE AVE
Second Line	:
City	:	MENLO PARK
State	:	CA
Zip	:	94025-4434
Country	:	US
Telephone Number	:	650-323-5211
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 OAK GROVE AVE
Second Line	:
City	:	MENLO PARK
State	:	CA
Zip	:	94025-4434
Country	:	US
Telephone Number	:	650-323-5211
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. R. GLENN KITASOE
Credential	:	DDS
Telephone Number	:	650-323-5211

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	11/23/2015

Similar Medicare Providers

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Practice Location Address:

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94025-4434

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1497161541 — DR. ANDREA ELIZABETH YALEY DMD
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1720821002 — MOLLY CLUFF OTR
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