Provider Demographics
NPI:1992922447
Name:BICKERT, GLENN W (DMD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:W
Last Name:BICKERT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:G
Other - Middle Name:W
Other - Last Name:BICKERT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:21611 MIDCREST DR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6584
Mailing Address - Country:US
Mailing Address - Phone:949-400-6923
Mailing Address - Fax:949-581-5227
Practice Address - Street 1:25261 PASEO DE VALENCIA
Practice Address - Street 2:SUITE 2
Practice Address - City:LAGUNA WOODS
Practice Address - State:CA
Practice Address - Zip Code:92637-4966
Practice Address - Country:US
Practice Address - Phone:949-951-7988
Practice Address - Fax:949-581-5227
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA272361223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics