Provider Demographics
NPI:1538557640
Name:GLOW COMPREHENSIVE DENTISTRY, PC
Entity type:Organization
Organization Name:GLOW COMPREHENSIVE DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-350-3815
Mailing Address - Street 1:850 W HAPPY CANYON RD
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80108-3908
Mailing Address - Country:US
Mailing Address - Phone:303-688-5705
Mailing Address - Fax:303-688-5731
Practice Address - Street 1:850 W HAPPY CANYON RD
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80108-3908
Practice Address - Country:US
Practice Address - Phone:303-688-5705
Practice Address - Fax:303-688-5731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-26
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10093122300000X
CO10514122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty