=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760724967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLICK DENTAL ASSOCIATE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2013
-----------------------------------------------------
Last Update Date | 03/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4250 BROADWAY SUITE 5W
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-795-0765
-----------------------------------------------------
Fax | 212-795-3600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4250 BROADWAY SUITE 5W
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-795-0765
-----------------------------------------------------
Fax | 212-795-3600
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MOSHA GLICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-865-2446
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0550291
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------