Provider Demographics
NPI:1700862059
Name:GORAB, GLENN N (DMD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:N
Last Name:GORAB
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1439 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-4221
Mailing Address - Country:US
Mailing Address - Phone:973-778-7171
Mailing Address - Fax:973-916-0696
Practice Address - Street 1:1439 BROAD ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-4221
Practice Address - Country:US
Practice Address - Phone:973-778-7171
Practice Address - Fax:973-916-0696
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI130231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ185953RWUMedicare ID - Type Unspecified
G0185953Medicare UPIN