MEDICARE: DR. CRAIG ALLEN GLICK DDS

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	1223G0001X	General Practice Dentistry	DX34704	CA

General Provider Information

NPI Number	:	1508933912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CRAIG ALLEN GLICK DDS

Provider Business Mailing Address
First Line	:	17547 VENTURA BLVD
Second Line	:	SUITE 103
City	:	ENCINO
State	:	CA
Zip	:	91316-3853
Country	:	US
Telephone Number	:	818-990-8550
Fax Number	:	818-990-8551

Provider Business Practice Location Address
First Line	:	17547 VENTURA BLVD
Second Line	:	SUITE 103
City	:	ENCINO
State	:	CA
Zip	:	91316-3853
Country	:	US
Telephone Number	:	818-990-8550
Fax Number	:	818-990-8551

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	07/08/2007

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