Healthcare Provider Details

I. General information

NPI: 1891112249
Provider Name (Legal Business Name): ROGER W. ASHWORTH A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 03/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 FIFTH STREET
ARBUCKLE CA
95912
US

IV. Provider business mailing address

20030 OLD RIVER RD
WEST SACRAMENTO CA
95691-8004
US

V. Phone/Fax

Practice location:
  • Phone: 530-476-2219
  • Fax: 530-476-2930
Mailing address:
  • Phone: 916-919-1841
  • Fax: 530-476-2930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number25118
License Number StateCA

VIII. Authorized Official

Name: DR. ROGER WALTER ASHWORTH
Title or Position: OWNER
Credential: DDS
Phone: 916-919-1841