Provider Demographics
NPI:1811789340
Name:GLISTEN DENTAL GLENDALE
Entity type:Organization
Organization Name:GLISTEN DENTAL GLENDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:623-262-4372
Mailing Address - Street 1:4365 E PECOS RD STE 127
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-8052
Mailing Address - Country:US
Mailing Address - Phone:623-262-4372
Mailing Address - Fax:
Practice Address - Street 1:4901 W BELL RD STE 140
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3416
Practice Address - Country:US
Practice Address - Phone:602-671-0303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty