Provider Demographics
NPI:1871897983
Name:COLE, GLEN W (DDS)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:W
Last Name:COLE
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 1:29 W HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-3309
Mailing Address - Country:US
Mailing Address - Phone:215-242-1662
Mailing Address - Fax:215-247-0234
Practice Address - Street 1:29 W HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-3309
Practice Address - Country:US
Practice Address - Phone:215-242-1662
Practice Address - Fax:215-247-0234
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS016907L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice