Glen A. Tistaert, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

18421 Issued in CA

Practice address

1333 7TH St
Santa Monica, CA 90401-1607

Phone

(310) 394-2661

Fax

(310) 450-9451

NPI assigned

Apr 19, 2007

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176940800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1184841207",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2648 34TH ST",
            "city": "SANTA MONICA",
            "state": "CA",
            "postal_code": "904053115",
            "telephone_number": "310-394-2661",
            "fax_number": "310-451-8971"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1333 7TH ST",
            "city": "SANTA MONICA",
            "state": "CA",
            "postal_code": "904011607",
            "telephone_number": "310-394-2661",
            "fax_number": "310-450-9451"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TISTAERT",
        "first_name": "GLEN",
        "middle_name": "A.",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-04-19",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "CA",
            "license": "18421",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• General Practice Dentistry in Santa Monica, CA
• Providers in Santa Monica, CA by specialty
• General Practice Dentistry in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.