MEDICARE: ASHLEY ELIZABETH WILSON DENTAL HYGIENIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	DH.002024806	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DH.002024806	OTHER	CO	DORA - DENTAL HYGIENE LICENSE.

General Provider Information

NPI Number	:	1215424353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY ELIZABETH WILSON DENTAL HYGIENIST

Provider Business Mailing Address
First Line	:	7558 FOREST VALLEY LOOP
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80908-5647
Country	:	US
Telephone Number	:	757-351-9180
Fax Number	:

Provider Business Practice Location Address
First Line	:	1079 SPACE CENTER DR UNIT 100
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-3612
Country	:	US
Telephone Number	:	719-596-3481
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2018
Last Update Date	:	04/14/2018

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