Provider Demographics
NPI:1427416353
Name:COX, GLADE
Entity Type:Individual
Prefix:
First Name:GLADE
Middle Name:
Last Name:COX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 LINCOLN PL # 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-4141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220
Practice Address - Country:US
Practice Address - Phone:718-630-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-06
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP97309390200000X
AZ99391223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program