Provider Demographics
NPI:1902063134
Name:GLENN A MEAD DDS PC
Entity Type:Organization
Organization Name:GLENN A MEAD DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:MEAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-527-6568
Mailing Address - Street 1:129 N 3RD AVE STE B
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-4246
Mailing Address - Country:US
Mailing Address - Phone:405-527-6568
Mailing Address - Fax:405-527-6569
Practice Address - Street 1:129 N 3RD AVE STE B
Practice Address - Street 2:129 N 3RD AVE STE B
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-4246
Practice Address - Country:US
Practice Address - Phone:405-527-6568
Practice Address - Fax:405-527-6569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3856122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100088780 AMedicaid