Provider Demographics
NPI:1891134383
Name:GLAVASH, MYRIAM
Entity Type:Individual
Prefix:
First Name:MYRIAM
Middle Name:
Last Name:GLAVASH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 121ST LN
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-1386
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6309 4TH ST STE 100
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-4281
Practice Address - Country:US
Practice Address - Phone:806-516-0090
Practice Address - Fax:806-516-0091
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX322871223G0001X, 1223P0221X
FLDN201611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice