Provider Demographics
NPI:1285741421
Name:STEPHEN E. GLICK, DDS, PC
Entity type:Organization
Organization Name:STEPHEN E. GLICK, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:GLICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-784-4150
Mailing Address - Street 1:1600 HOCKETT RD
Mailing Address - Street 2:
Mailing Address - City:MANAKIN SABOT
Mailing Address - State:VA
Mailing Address - Zip Code:23103-2229
Mailing Address - Country:US
Mailing Address - Phone:804-784-4150
Mailing Address - Fax:804-784-1232
Practice Address - Street 1:1600 HOCKETT RD
Practice Address - Street 2:
Practice Address - City:MANAKIN SABOT
Practice Address - State:VA
Practice Address - Zip Code:23103-2229
Practice Address - Country:US
Practice Address - Phone:804-784-4150
Practice Address - Fax:804-784-1232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014102431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty