Provider Demographics
NPI:1962502120
Name:GLEN R DEAN DDS PC
Entity type:Organization
Organization Name:GLEN R DEAN DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:ROYDEN
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:970-241-1313
Mailing Address - Street 1:2525 NORTH 8TH STREET
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8258
Mailing Address - Country:US
Mailing Address - Phone:970-241-1313
Mailing Address - Fax:970-241-5202
Practice Address - Street 1:2525 NORTH 8TH STREET
Practice Address - Street 2:SUITE 105
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8258
Practice Address - Country:US
Practice Address - Phone:970-241-1313
Practice Address - Fax:970-241-5202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1044231223P0221X
UT13565399221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04015236Medicaid