Provider Demographics
NPI:1114316361
Name:SANDERS, ASHLEY NICHOLE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICHOLE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 N DOOLY ST
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA
Mailing Address - State:GA
Mailing Address - Zip Code:31063-1309
Mailing Address - Country:US
Mailing Address - Phone:478-832-8979
Mailing Address - Fax:
Practice Address - Street 1:607 N DOOLY ST
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:GA
Practice Address - Zip Code:31063-1309
Practice Address - Country:US
Practice Address - Phone:478-832-8979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA693589712122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist