Healthcare Provider Details

I. General information

NPI: 1972570356
Provider Name (Legal Business Name): STEPHEN J GLAWSON SR. D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MADISON AVE
LAKEWOOD NJ
08701-3214
US

IV. Provider business mailing address

1403 HOLMES AVE
TOMS RIVER NJ
08753-6925
US

V. Phone/Fax

Practice location:
  • Phone: 732-363-0800
  • Fax: 732-367-5206
Mailing address:
  • Phone: 732-363-0800
  • Fax: 732-367-5206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number15866
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: