Provider Demographics
NPI:1053535757
Name:ADAMS, GLEN DAVID (LP, CCP)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:DAVID
Last Name:ADAMS
Suffix:
Gender:M
Credentials:LP, CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7317 WAKE FORREST DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-1750
Mailing Address - Country:US
Mailing Address - Phone:214-503-6144
Mailing Address - Fax:
Practice Address - Street 1:3409 WORTH ST
Practice Address - Street 2:SUITE 725
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2029
Practice Address - Country:US
Practice Address - Phone:214-824-2510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPF0046242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist