MEDICARE: GLENN FAMILY DENTISTRY, PROFESSIONAL LLC

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	9518	CO
2	1223G0001X	General Practice Dentistry	3462	CO

General Provider Information

NPI Number	:	1942477153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENN FAMILY DENTISTRY, PROFESSIONAL LLC

Provider Business Mailing Address
First Line	:	3600 S BEELER ST
Second Line	:	SUITE 120
City	:	DENVER
State	:	CO
Zip	:	80237-1801
Country	:	US
Telephone Number	:	303-779-2592
Fax Number	:	303-779-2522

Provider Business Practice Location Address
First Line	:	3600 S BEELER ST
Second Line	:	SUITE 120
City	:	DENVER
State	:	CO
Zip	:	80237-1801
Country	:	US
Telephone Number	:	303-779-2592
Fax Number	:	303-779-2522

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. DEWAYNE LEE GLENN
Credential	:	DDS
Telephone Number	:	303-779-2592

Provider Enumeration Date	:	05/15/2008
Last Update Date	:	05/15/2008

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