Provider Demographics
NPI:1134722077
Name:BURGHOLZER, ASHLEY ANN (RDH)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ANN
Last Name:BURGHOLZER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:ANN
Other - Last Name:HARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5000 US HIGHWAY 17 STE 4
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-8237
Mailing Address - Country:US
Mailing Address - Phone:904-215-7855
Mailing Address - Fax:
Practice Address - Street 1:5000 US HIGHWAY 17 STE 4
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-8237
Practice Address - Country:US
Practice Address - Phone:904-215-7855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH28037124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist