Provider Demographics
NPI:1194926287
Name:ROCHLEN, GLENN KEVIN (DENTIST)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:KEVIN
Last Name:ROCHLEN
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 TONI PL
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-3041
Mailing Address - Country:US
Mailing Address - Phone:718-479-4100
Mailing Address - Fax:
Practice Address - Street 1:11206 SPRINGFIELD BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-2650
Practice Address - Country:US
Practice Address - Phone:718-479-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0404181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01285890Medicaid