=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831410281
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN SCOTT ASHTON D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2010
-----------------------------------------------------
Last Update Date | 06/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 808 NE MALL BLVD
-----------------------------------------------------
City | HURST
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76053-4653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-595-9675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4552 HICKORY MEADOWS LN
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76244-5847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-562-3288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 25484
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------