Provider Demographics
NPI:1104928555
Name:FRITZ, GLENN WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:WILLIAM
Last Name:FRITZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4053 TAYLOR RD SUITE M
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5526
Mailing Address - Country:US
Mailing Address - Phone:757-484-9441
Mailing Address - Fax:757-484-8821
Practice Address - Street 1:4053 TAYLOR RD SUITE M
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5526
Practice Address - Country:US
Practice Address - Phone:757-484-9441
Practice Address - Fax:757-484-8821
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401004845122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA52237OtherSENTARA
VA873455OtherUNITED CONCORDIA
VA25239OtherOPTIMA
VA260227OtherANTHEM BCBS
T21698Medicare UPIN