Provider Demographics
NPI:1285604553
Name:GLIDDON, MICHAEL JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:GLIDDON
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 1:3617 W. GORE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6373
Mailing Address - Country:US
Mailing Address - Phone:580-357-0888
Mailing Address - Fax:580-248-1860
Practice Address - Street 1:3617 W. GORE BLVD.
Practice Address - Street 2:SUITE B
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6373
Practice Address - Country:US
Practice Address - Phone:580-357-0888
Practice Address - Fax:580-248-1860
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX194221223S0112X
OK1601223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200345180AMedicaid