Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | IL |
NPI | 1417006511 |
---|---|
Provider Name | Dr. Brian Glesne |
First Address | Pekin, IL 61554-6237 |
Second Address | Pekin, IL 61554-6237 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/01/2007 |
Last Update Date | 08/07/2007 |