Provider Demographics
NPI:1083002463
Name:ASHMORE DENTAL CORPORATION
Entity Type:Organization
Organization Name:ASHMORE DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:CASEY
Authorized Official - Last Name:ASHMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-701-6622
Mailing Address - Street 1:4110 W POINT LOMA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5603
Mailing Address - Country:US
Mailing Address - Phone:619-701-6622
Mailing Address - Fax:
Practice Address - Street 1:4110 W POINT LOMA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5603
Practice Address - Country:US
Practice Address - Phone:619-701-6622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63198122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty