Provider Demographics
NPI:1508933912
Name:GLICK, CRAIG ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:ALLEN
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 1:17547 VENTURA BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3853
Mailing Address - Country:US
Mailing Address - Phone:818-990-8550
Mailing Address - Fax:818-990-8551
Practice Address - Street 1:17547 VENTURA BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3853
Practice Address - Country:US
Practice Address - Phone:818-990-8550
Practice Address - Fax:818-990-8551
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADX347041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice