Healthcare Provider Details

I. General information

NPI: 1841676418
Provider Name (Legal Business Name): ASHLEY TA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 N LOS ROBLES AVE APT 7
PASADENA CA
91101-1092
US

IV. Provider business mailing address

570 N LOS ROBLES AVE APT 7
PASADENA CA
91101-1092
US

V. Phone/Fax

Practice location:
  • Phone: 585-309-2592
  • Fax:
Mailing address:
  • Phone: 585-309-2592
  • Fax: 585-273-1235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number104669
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: