1437541737 NPI number — GLENN CASEY ASHMORE DENTAL CORP.

Table of content: (NPI 1437541737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437541737 NPI number — GLENN CASEY ASHMORE DENTAL CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLENN CASEY ASHMORE DENTAL CORP.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DENTAL EXPRESS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437541737
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4664 CLAIREMONT MESA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92117-2005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-701-6625
Provider Business Mailing Address Fax Number:
619-701-6769

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4110 W POINT LOMA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-5603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-701-6622
Provider Business Practice Location Address Fax Number:
619-701-6656
Provider Enumeration Date:
02/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ASHMORE
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
CASEY
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
619-701-6622

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  63198 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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