Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 010345 | GA |
N | 204E00000X | Oral & Maxillofacial Surgeon | 10345 | GA |
NPI | 1295791549 |
---|---|
Provider Name | Glenn Maron |
First Address | Atlanta, GA 30342-2018 |
Second Address | Atlanta, GA 30309 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2006 |
Last Update Date | 19/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U19478 | (02) |