Provider Demographics
NPI:1326890658
Name:ASHBY, JACK THOMAS
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:THOMAS
Last Name:ASHBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32054 CONLEYS CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-6021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11352 N WILLIAMS ST STE 505
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34432-8312
Practice Address - Country:US
Practice Address - Phone:352-533-5030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN30221122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist