Provider Demographics
NPI:1790966133
Name:GLOSMAN DENTAL GROUP, LTD
Entity Type:Organization
Organization Name:GLOSMAN DENTAL GROUP, LTD
Other - Org Name:DENTALVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OF STAFF
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GLOSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-480-2307
Mailing Address - Street 1:833 W WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4735
Mailing Address - Country:US
Mailing Address - Phone:323-266-1000
Mailing Address - Fax:323-372-1662
Practice Address - Street 1:7101 W CRAIG RD
Practice Address - Street 2:#102
Practice Address - City:LOS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-6059
Practice Address - Country:US
Practice Address - Phone:702-515-0955
Practice Address - Fax:702-515-0558
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GLOSMAN DENTAL GROUP, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-14
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3850122300000X
NV3580122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100512442Medicaid