Provider Demographics
NPI:1053322891
Name:HOECKER, GLEN RAY (DDS)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:RAY
Last Name:HOECKER
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 1:217 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-4538
Mailing Address - Country:US
Mailing Address - Phone:580-765-4553
Mailing Address - Fax:580-765-4553
Practice Address - Street 1:217 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-4538
Practice Address - Country:US
Practice Address - Phone:580-765-4553
Practice Address - Fax:580-765-4553
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK41141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice