Provider Demographics
NPI:1063431237
Name:GLICK, BENJAMIN H (DMD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:H
Last Name:GLICK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX PH
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-8000
Mailing Address - Country:US
Mailing Address - Phone:928-674-7156
Mailing Address - Fax:
Practice Address - Street 1:US HIGHWAY 191 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-7156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4281122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist