Healthcare Provider Details

I. General information

NPI: 1194150425
Provider Name (Legal Business Name): TORI ASHLEY MAYWALT DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/24/2023
Certification Date: 09/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USNMRTU IWAKUNI, BLDG 110, MCAS IWAKUNI 1 MISUMI MACHI
IWAKUNI YAMAGUCHI
7400025
JP

IV. Provider business mailing address

USNMRTU IWAKUNI BLDG 110 MCAS IWAKUNI IWAKUNI, 1 MISUMI MACHI
IWAKUNI YAMAGUCHI
7400025
JP

V. Phone/Fax

Practice location:
  • Phone: 315-255-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3697-13
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3697-13
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: