Healthcare Provider Details

I. General information

NPI: 1053538504
Provider Name (Legal Business Name): E. GLENN GLASSMAN, D.D.S. PC DBA ORTHOCARE SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6925 S LINDBERGH BLVD
SAINT LOUIS MO
63125-4220
US

IV. Provider business mailing address

709 S 5TH ST
SAINT CHARLES MO
63301-2913
US

V. Phone/Fax

Practice location:
  • Phone: 314-892-8550
  • Fax: 314-892-5403
Mailing address:
  • Phone: 636-757-0770
  • Fax: 636-757-0773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number013277
License Number StateMO

VIII. Authorized Official

Name: DR. ELLIOT GLENN GLASSMAN
Title or Position: OWNER
Credential: DDS
Phone: 636-757-0770