Healthcare Provider Details

I. General information

NPI: 1467787846
Provider Name (Legal Business Name): ROBIN JOY GLOECKNER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 01/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 TEJAS PL
NIPOMO CA
93444-9123
US

IV. Provider business mailing address

150 TEJAS PL PO BOX 430
NIPOMO CA
93444-9123
US

V. Phone/Fax

Practice location:
  • Phone: 805-929-3254
  • Fax: 805-931-2569
Mailing address:
  • Phone: 805-929-3211
  • Fax: 805-929-6359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number24336
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number52095
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierFHC70477F
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer
# 2
IdentifierFHC03884F
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: