Provider Demographics
NPI:1104312107
Name:O'BRIEN, ASHLEY
Entity type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 CITY AVE APT J702
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-3044
Mailing Address - Country:US
Mailing Address - Phone:607-342-8654
Mailing Address - Fax:
Practice Address - Street 1:187 W CITY AVE
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-3102
Practice Address - Country:US
Practice Address - Phone:607-342-8654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041788122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty