Provider Demographics
NPI:1528260171
Name:REYNOLDS, GLENDA CHARLENE (DDS)
Entity type:Individual
Prefix:DR
First Name:GLENDA
Middle Name:CHARLENE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:894 CAMPUS DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1644
Mailing Address - Country:US
Mailing Address - Phone:906-483-1445
Mailing Address - Fax:906-483-1122
Practice Address - Street 1:56720 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:CALUMET
Practice Address - State:MI
Practice Address - Zip Code:49913-1967
Practice Address - Country:US
Practice Address - Phone:906-483-1177
Practice Address - Fax:906-483-1188
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH26371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH000800643OtherAPWU PROVIDER ID
NHUS00XXXXX00000010000OtherDELTA PROVIDER ID
NH000891547OtherUNITED CONCORDIA PROVIDER
NH000304310 AOtherEMPLOYEE BENEFIT ID #
NH000891547OtherUNITED CONCORDIA PROVIDER