Provider Demographics
NPI:1518059617
Name:GLYMAN, MARK L (MD,DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:GLYMAN
Suffix:
Gender:M
Credentials:MD,DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2030 E FLAMINGO RD
Mailing Address - Street 2:288
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-0818
Mailing Address - Country:US
Mailing Address - Phone:702-892-0833
Mailing Address - Fax:702-892-0906
Practice Address - Street 1:2030 E FLAMINGO RD
Practice Address - Street 2:288
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-0818
Practice Address - Country:US
Practice Address - Phone:702-892-0833
Practice Address - Fax:702-892-0906
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV6502204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV20-19211Medicaid
NV20-19211Medicaid
NV30650Medicare ID - Type UnspecifiedMEDICARE NUMBER