Provider Demographics
NPI:1992785711
Name:GLICK, KIM R (DDS)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:R
Last Name:GLICK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-3649
Mailing Address - Country:US
Mailing Address - Phone:931-455-3917
Mailing Address - Fax:
Practice Address - Street 1:208 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-3649
Practice Address - Country:US
Practice Address - Phone:931-455-3917
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000045681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0099288OtherBLUE CROSS BLUE SHIELD
TN3225332Medicaid