Healthcare Provider Details

I. General information

NPI: 1467760850
Provider Name (Legal Business Name): GLENN THOMAS ASHWORTH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 05/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 PACIFIC AVE SUITE 101
TACOMA WA
98418-7825
US

IV. Provider business mailing address

3820 PACIFIC AVE SUITE 101
TACOMA WA
98418-7825
US

V. Phone/Fax

Practice location:
  • Phone: 716-425-6295
  • Fax:
Mailing address:
  • Phone: 716-425-6295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE 60462145
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14600
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: