MEDICARE: DR. MICHAEL GLASS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	10551	MI

General Provider Information

NPI Number	:	1609816644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL GLASS D.D.S.

Provider Business Mailing Address
First Line	:	1460 WALTON BLVD
Second Line	:	SUITE 208
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48309-1768
Country	:	US
Telephone Number	:	284-656-1626
Fax Number	:	248-656-3147

Provider Business Practice Location Address
First Line	:	1460 WALTON BLVD
Second Line	:	SUITE 208
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48309-1768
Country	:	US
Telephone Number	:	284-656-1626
Fax Number	:	248-656-3147

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	07/08/2007

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