MEDICARE: GREGORY L GLADE DMD PC

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	122300000X	Dentist		IL

General Provider Information

NPI Number	:	1609965763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREGORY L GLADE DMD PC

Provider Business Mailing Address
First Line	:	308 11TH ST NORTH
Second Line	:
City	:	PORT BYRON
State	:	IL
Zip	:	61275-9038
Country	:	US
Telephone Number	:	309-523-3325
Fax Number	:	309-523-9078

Provider Business Practice Location Address
First Line	:	308 11TH ST NORTH
Second Line	:
City	:	PORT BYRON
State	:	IL
Zip	:	61275-9038
Country	:	US
Telephone Number	:	309-523-3325
Fax Number	:	309-523-9078

Authorized Official
Title or Position	:	SECRETARY OF PC OFFICE MANAGER
Name	:	MRS. BERNADETTE L GLADE
Credential	:
Telephone Number	:	309-523-3325

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	08/22/2020

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