Provider Demographics
NPI:1053387605
Name:GLASSEY, JENNIFER L (DMD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:GLASSEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MERRIFIELD CT
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-9266
Mailing Address - Country:US
Mailing Address - Phone:352-219-5876
Mailing Address - Fax:
Practice Address - Street 1:16 WEINBERG ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-2629
Practice Address - Country:US
Practice Address - Phone:803-435-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN167261223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076011100Medicaid