Healthcare Provider Details

I. General information

NPI: 1396300034
Provider Name (Legal Business Name): LAKIA MERCEDES GLOVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120 WOODLAND AVE FL 2
PHILADELPHIA PA
19142-3200
US

IV. Provider business mailing address

4700 WISSAHICKON AVE STE 118
PHILADELPHIA PA
19144-4248
US

V. Phone/Fax

Practice location:
  • Phone: 267-597-5226
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH068098
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: