Provider Demographics
NPI:1205500147
Name:DETWILER, TASHANA (DMD)
Entity type:Individual
Prefix:
First Name:TASHANA
Middle Name:
Last Name:DETWILER
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 1:5008 SHADOW PINE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-5142
Mailing Address - Country:US
Mailing Address - Phone:704-780-3714
Mailing Address - Fax:
Practice Address - Street 1:280 CONCORD PKWY S STE 110A
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-2704
Practice Address - Country:US
Practice Address - Phone:704-920-1070
Practice Address - Fax:704-920-1071
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC124201223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health