Provider Demographics
NPI:1588687388
Name:BRANCA, GLENN ANDREW (DDS)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ANDREW
Last Name:BRANCA
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 1:104 TREMONT ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:DUXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02332-4750
Mailing Address - Country:US
Mailing Address - Phone:781-934-8101
Mailing Address - Fax:781-934-8187
Practice Address - Street 1:104 TREMONT ST
Practice Address - Street 2:SUITE 5
Practice Address - City:DUXBURY
Practice Address - State:MA
Practice Address - Zip Code:02332-4750
Practice Address - Country:US
Practice Address - Phone:781-934-8101
Practice Address - Fax:781-934-8187
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211911223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX09281OtherBLUE CROSS BLUE SHIELD
MAAA36031OtherHPHC
MAU99005Medicare UPIN
MAX20152Medicare ID - Type Unspecified