Provider Demographics
NPI:1104915230
Name:GLICKMAN, ROBERT STUART (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:STUART
Last Name:GLICKMAN
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 1:530 FIRST AVE
Mailing Address - Street 2:SUITE 9Q NYU MEDICAL CENTER
Mailing Address - City:NEW YORK CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10016
Mailing Address - Country:US
Mailing Address - Phone:212-263-7552
Mailing Address - Fax:212-995-4920
Practice Address - Street 1:530 FIRST AVE
Practice Address - Street 2:SUITE 9Q NYU MEDICAL CENTER
Practice Address - City:NEW YORK CITY
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-263-7552
Practice Address - Fax:212-995-4920
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034185-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0072977Medicaid
NYD7D671Medicare ID - Type UnspecifiedMEDICARE
NY0072977Medicaid