Provider Demographics
NPI:1821544438
Name:GLICK, LINDA ANN (CDA EFDA)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:ANN
Last Name:GLICK
Suffix:
Gender:F
Credentials:CDA EFDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5047 VIRGINIA AVE.
Mailing Address - Street 2:HARPER DENTAL CLINIC BLD 500
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-1317
Mailing Address - Country:US
Mailing Address - Phone:573-596-0408
Mailing Address - Fax:573-596-0314
Practice Address - Street 1:5047 VIRGINIA AVE.
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-1317
Practice Address - Country:US
Practice Address - Phone:573-596-0408
Practice Address - Fax:573-596-0314
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013015015126800000X
MO2013015016126800000X
MO2013015017126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant