Provider Demographics
NPI:1053401034
Name:STERN, GLENN ALLEN
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:ALLEN
Last Name:STERN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:GLEN
Other - Middle Name:ALLEN
Other - Last Name:STERN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:240 E HIGHWAY 243
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:TX
Mailing Address - Zip Code:75103-2315
Mailing Address - Country:US
Mailing Address - Phone:903-567-4884
Mailing Address - Fax:903-567-5149
Practice Address - Street 1:240 E HIGHWAY 243
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-2315
Practice Address - Country:US
Practice Address - Phone:903-567-4884
Practice Address - Fax:903-567-5149
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20071122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist