Healthcare Provider Details

I. General information

NPI: 1821544438
Provider Name (Legal Business Name): LINDA ANN GLICK C.D.A. EFDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5047 VIRGINIA AVE.
FORT LEONARD WOOD MO
65473-1317
US

IV. Provider business mailing address

5047 VIRGINIA AVE. HARPER DENTAL CLINIC BLD 500
FORT LEONARD WOOD MO
65473-1317
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-0408
  • Fax: 573-596-0314
Mailing address:
  • Phone: 573-596-0408
  • Fax: 573-596-0314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number2013015015
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number2013015016
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number2013015017
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: