Healthcare Provider Details

I. General information

NPI: 1932137296
Provider Name (Legal Business Name): GEOFFREY MICHAEL GLICK D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 PARK ST
MEDFIELD MA
02052-2518
US

IV. Provider business mailing address

395 CAPTAIN EAMES CIR
ASHLAND MA
01721-3918
US

V. Phone/Fax

Practice location:
  • Phone: 508-359-2576
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number19785
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: