MEDICARE: GLENN CASEY 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	1223G0001X	General Practice Dentistry	63198	CA

General Provider Information

NPI Number	:	1437541737
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENN CASEY ASHMORE DENTAL CORP.

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

Provider Business Practice Location 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	:	619-701-6656

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

Provider Enumeration Date	:	02/23/2015
Last Update Date	:	06/26/2015

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