Provider Demographics
NPI:1487874343
Name:KOMAE, GLENN TETSUO (DDS)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:TETSUO
Last Name:KOMAE
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 1:16882 BOLSA CHICA ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3592
Mailing Address - Country:US
Mailing Address - Phone:714-846-2837
Mailing Address - Fax:714-840-6657
Practice Address - Street 1:16882 BOLSA CHICA ST
Practice Address - Street 2:SUITE 204
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-3592
Practice Address - Country:US
Practice Address - Phone:714-846-2837
Practice Address - Fax:714-840-6657
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22631122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist