Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 26442 | TX |
N | 1223P0221X | Pediatric Dentist | 3732 | AR |
NPI | 1053545665 |
---|---|
Provider Name | Dr. David Mitchell Glass |
First Address | Shreveport, LA 71106-1118 |
Second Address | Texarkana, TX 75503 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/05/2009 |
Last Update Date | 13/06/2011 |