Provider Demographics
NPI:1366596306
Name:NAKPAWAN, GLENFORD (DDS)
Entity type:Individual
Prefix:DR
First Name:GLENFORD
Middle Name:
Last Name:NAKPAWAN
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 1:19066 BRASILIA DR
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-1520
Mailing Address - Country:US
Mailing Address - Phone:914-835-6004
Mailing Address - Fax:
Practice Address - Street 1:875 MAMARONECK AVE
Practice Address - Street 2:SUITE 100A
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-1900
Practice Address - Country:US
Practice Address - Phone:914-835-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0516081223G0001X
CA52438122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02634839Medicaid