Provider Demographics
NPI:1336291285
Name:GLIME, MARK A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:GLIME
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 S MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4013
Mailing Address - Country:US
Mailing Address - Phone:920-437-3376
Mailing Address - Fax:920-437-8474
Practice Address - Street 1:315 S MONROE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4013
Practice Address - Country:US
Practice Address - Phone:920-437-3376
Practice Address - Fax:920-437-8474
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice