Provider Demographics
NPI:1891112249
Name:ROGER W. ASHWORTH A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ROGER W. ASHWORTH A PROFESSIONAL CORPORATION
Other - Org Name:SMILE ART DENTAL ARBUCKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:ASHWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-919-1841
Mailing Address - Street 1:20030 OLD RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-8004
Mailing Address - Country:US
Mailing Address - Phone:916-919-1841
Mailing Address - Fax:530-476-2930
Practice Address - Street 1:102 FIFTH STREET
Practice Address - Street 2:
Practice Address - City:ARBUCKLE
Practice Address - State:CA
Practice Address - Zip Code:95912
Practice Address - Country:US
Practice Address - Phone:530-476-2219
Practice Address - Fax:530-476-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25118261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental