Provider Demographics
NPI:1528287232
Name:GLOSMAN DENTAL GROUP, LTD
Entity type:Organization
Organization Name:GLOSMAN DENTAL GROUP, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF STAFF
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GLOSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-480-2307
Mailing Address - Street 1:833 W WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4735
Mailing Address - Country:US
Mailing Address - Phone:323-266-1000
Mailing Address - Fax:323-859-3198
Practice Address - Street 1:9210 S. EASTERN AVE #130,
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-4834
Practice Address - Country:US
Practice Address - Phone:702-492-6606
Practice Address - Fax:702-492-1580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV35801223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002202150Medicaid