Provider Demographics
NPI:1184695835
Name:WILLOUGHBY, TASHA N (DDS)
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:N
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2557 COWAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-8440
Mailing Address - Country:US
Mailing Address - Phone:540-551-5550
Mailing Address - Fax:540-371-0000
Practice Address - Street 1:2557 COWAN BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-8440
Practice Address - Country:US
Practice Address - Phone:540-551-5550
Practice Address - Fax:540-371-0000
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411109122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9179325Medicaid