MEDICARE: G.C. ASHMORE DENTAL CORP.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6319	CA

General Provider Information

NPI Number	:	1346773629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	G.C. ASHMORE DENTAL CORP.

Provider Business Mailing Address
First Line	:	4110 W POINT LOMA BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-5603
Country	:	US
Telephone Number	:	619-701-6622
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 PARK BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-7414
Country	:	US
Telephone Number	:	619-701-6628
Fax Number	:

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	GLENN CASEY ASHMORE
Credential	:	DDS
Telephone Number	:	619-701-6622

Provider Enumeration Date	:	04/04/2017
Last Update Date	:	04/04/2017

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