MEDICARE: JEREMY GLICK

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	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	00204578	CO

General Provider Information

NPI Number	:	1952936817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY GLICK

Provider Business Mailing Address
First Line	:	906 N CORNWALL AVE
Second Line	:
City	:	VENTNOR CITY
State	:	NJ
Zip	:	08406-1116
Country	:	US
Telephone Number	:	609-412-3613
Fax Number	:

Provider Business Practice Location Address
First Line	:	13731 E RICE PL STE 100
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80015-1063
Country	:	US
Telephone Number	:	720-938-0708
Fax Number	:

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

Provider Enumeration Date	:	03/11/2020
Last Update Date	:	11/01/2023

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Directions to “ JEREMY GLICK ” Practice Location

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