1518189117 NPI number — IAN ANDREW GLASER DDS PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518189117 NPI number — IAN ANDREW GLASER DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IAN ANDREW GLASER DDS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518189117
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 LANDING AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMITHTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11787-2711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-724-1200
Provider Business Mailing Address Fax Number:
631-724-1201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 LANDING AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMITHTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11787-2711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-724-1200
Provider Business Practice Location Address Fax Number:
631-724-1201
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GLASER
Authorized Official First Name:
IAN
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
631-724-1200

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  036700 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00908801 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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