Provider Demographics
NPI:1356562482
Name:ABRAHAM, GLEN R (DDS)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:R
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 SPRING CYPRESS RD STE E
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-3447
Mailing Address - Country:US
Mailing Address - Phone:281-374-7100
Mailing Address - Fax:281-374-8425
Practice Address - Street 1:4740 SPRING CYPRESS RD STE E
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-3447
Practice Address - Country:US
Practice Address - Phone:281-374-7100
Practice Address - Fax:281-374-8425
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX186551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice