Provider Demographics
NPI:1518042266
Name:GLICK, JASON SCOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:SCOTT
Last Name:GLICK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2942 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1246
Mailing Address - Country:US
Mailing Address - Phone:847-905-0555
Mailing Address - Fax:
Practice Address - Street 1:2942 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1246
Practice Address - Country:US
Practice Address - Phone:847-905-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0022851223P0221X
IAFAC-402371223P0221X
IL0210022851223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901022932OtherSTATE OF MICHIGAN
IL021.002285OtherSTATE OF ILLINOIS
NY050551OtherNEW YORK STATE DENTAL LICENSE
IAFAC-40237OtherIOWA DENTAL BOARD