Provider Demographics
NPI:1508952946
Name:ASHBY, JOHN OTTIS JR (DDS MS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:OTTIS
Last Name:ASHBY
Suffix:JR
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4345 4 BONNEY ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1200
Mailing Address - Country:US
Mailing Address - Phone:757-340-7000
Mailing Address - Fax:757-498-6498
Practice Address - Street 1:4345 4 BONNEY ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1200
Practice Address - Country:US
Practice Address - Phone:757-340-7000
Practice Address - Fax:757-498-6498
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014112761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9181657Medicaid
VA1695363OtherUNITED CONCORDIA