Provider Demographics
NPI:1962579011
Name:GLANDER, JACK OTTO (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:OTTO
Last Name:GLANDER
Suffix:
Gender:
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:RR 1 BOX 87P
Mailing Address - Street 2:
Mailing Address - City:ROLETTE
Mailing Address - State:ND
Mailing Address - Zip Code:58366-9764
Mailing Address - Country:US
Mailing Address - Phone:701-246-3696
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:BELLCOURT
Practice Address - State:ND
Practice Address - Zip Code:58316
Practice Address - Country:US
Practice Address - Phone:701-477-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1384122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist