Provider Demographics
NPI:1376157396
Name:GLICK, JASON AUSTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:AUSTIN
Last Name:GLICK
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 1:1793 MADISON AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-7608
Mailing Address - Country:US
Mailing Address - Phone:631-877-0239
Mailing Address - Fax:
Practice Address - Street 1:3594 COVINGTON PIKE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-3926
Practice Address - Country:US
Practice Address - Phone:631-877-0239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11426122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist