Provider Demographics
NPI:1952936817
Name:GLICK, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:GLICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 N CORNWALL AVE
Mailing Address - Street 2:
Mailing Address - City:VENTNOR CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08406-1116
Mailing Address - Country:US
Mailing Address - Phone:609-412-3613
Mailing Address - Fax:
Practice Address - Street 1:13731 E RICE PL STE 100
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-1063
Practice Address - Country:US
Practice Address - Phone:720-938-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CO00204578122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program