Healthcare Provider Details

I. General information

NPI: 1568020238
Provider Name (Legal Business Name): ASHLEY JAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 01/30/2021
Certification Date: 01/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 MAIN ST
GREEN BAY WI
54302-3920
US

IV. Provider business mailing address

2127 AIRPARK DR
REDDING CA
96001-2433
US

V. Phone/Fax

Practice location:
  • Phone: 888-988-4066
  • Fax:
Mailing address:
  • Phone: 530-762-1139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number104541
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1002067
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: