=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104564657
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHTON TIERRA SAMUELS-POWELL DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2022
-----------------------------------------------------
Last Update Date | 05/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3800 SPRINGHURST BLVD STE F
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40241-6138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-339-7707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7040 SHANTY CREEK DR
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40228-2823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-572-0182
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 10766
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------