Provider Demographics
NPI:1922097898
Name:ASHMORE, GLENN CASEY (DDS)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:CASEY
Last Name:ASHMORE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 W POINT LOMA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5603
Mailing Address - Country:US
Mailing Address - Phone:619-701-6622
Mailing Address - Fax:619-701-6656
Practice Address - Street 1:4110 W POINT LOMA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5603
Practice Address - Country:US
Practice Address - Phone:619-701-6622
Practice Address - Fax:619-701-6656
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK57751223G0001X
CA631981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice