MEDICARE: GLOSMAN DENTAL GROUP, LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	3580	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164603502
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLOSMAN DENTAL GROUP, LTD

Provider Business Mailing Address
First Line	:	833 W WHITTIER BLVD
Second Line	:
City	:	MONTEBELLO
State	:	CA
Zip	:	90640-4735
Country	:	US
Telephone Number	:	323-266-1000
Fax Number	:	323-372-1662

Provider Business Practice Location Address
First Line	:	5060 S FORT APACHE RD
Second Line	:	#160
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-1731
Country	:	US
Telephone Number	:	702-851-8200
Fax Number	:	702-851-8201

Authorized Official
Title or Position	:	CHIEF OF STAFF
Name	:	MONIQUE R GLOSMAN
Credential	:	DDS
Telephone Number	:	310-480-2307

Provider Enumeration Date	:	11/14/2007
Last Update Date	:	06/07/2013

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