Healthcare Provider Details

I. General information

NPI: 1669495693
Provider Name (Legal Business Name): STEPHEN ERIC GLICK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 HOCKETT RD
MANAKIN SABOT VA
23103-2229
US

IV. Provider business mailing address

1600 HOCKETT RD
MANAKIN SABOT VA
23103-2229
US

V. Phone/Fax

Practice location:
  • Phone: 804-784-4150
  • Fax: 804-784-1232
Mailing address:
  • Phone: 804-784-4150
  • Fax: 804-784-1232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number401410243
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN15156
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: