Provider Demographics
NPI:1871689216
Name:OWENS, R GLENN JR (DDS)
Entity type:Individual
Prefix:
First Name:R
Middle Name:GLENN
Last Name:OWENS
Suffix:JR
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 1:4356 4 BONNEY ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1200
Mailing Address - Country:US
Mailing Address - Phone:757-340-7000
Mailing Address - Fax:757-498-6498
Practice Address - Street 1:4356 4 BONNEY ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1200
Practice Address - Country:US
Practice Address - Phone:757-340-7000
Practice Address - Fax:757-498-6498
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010031511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA326098OtherANTHEM BCBS
VA547859OtherUNITED CONCORDIA
VA7900104Medicaid