Healthcare Provider Details

I. General information

NPI: 1518421460
Provider Name (Legal Business Name): ASHLEY MOVALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 CESAR CHAVEZ ST
SAINT PAUL MN
55107-2226
US

IV. Provider business mailing address

153 CESAR CHAVEZ ST
SAINT PAUL MN
55107-2226
US

V. Phone/Fax

Practice location:
  • Phone: 651-602-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT113
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH10566
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: