Provider Demographics
NPI:1356967079
Name:GLOVER, JACY RAE (DDS)
Entity type:Individual
Prefix:
First Name:JACY
Middle Name:RAE
Last Name:GLOVER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 PINELAKE CT
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-7100
Mailing Address - Country:US
Mailing Address - Phone:405-623-3735
Mailing Address - Fax:
Practice Address - Street 1:201 S BERRY RD
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-5412
Practice Address - Country:US
Practice Address - Phone:405-360-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKT7301122300000X
OK7301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist