Provider Demographics
NPI:1609515535
Name:GOLDMAN, ASHLEY ROSE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:ROSE
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 WILLOW BEND RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-7580
Mailing Address - Country:US
Mailing Address - Phone:562-212-6092
Mailing Address - Fax:
Practice Address - Street 1:232 RICHMOND AVE E
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4652
Practice Address - Country:US
Practice Address - Phone:217-235-0448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033629122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist