Provider Demographics
NPI:1508967043
Name:DR GLENN A ASHMORE INC
Entity Type:Organization
Organization Name:DR GLENN A ASHMORE INC
Other - Org Name:DENTAL DEPOT
Other - Org Type:Other Name
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ASHMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-949-0123
Mailing Address - Street 1:2828 NW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-7404
Mailing Address - Country:US
Mailing Address - Phone:405-949-0123
Mailing Address - Fax:405-949-9762
Practice Address - Street 1:3104 NW 23
Practice Address - Street 2:
Practice Address - City:OKC
Practice Address - State:OK
Practice Address - Zip Code:73107
Practice Address - Country:US
Practice Address - Phone:405-949-0123
Practice Address - Fax:405-949-9762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKA=========Medicaid