Provider Demographics
NPI:1124142773
Name:ASHLEY, AMANDA GAYNOR (DMD, MSEDU, MS)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:GAYNOR
Last Name:ASHLEY
Suffix:
Gender:F
Credentials:DMD, MSEDU, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 NATCHEZ TRACE AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7995
Mailing Address - Country:US
Mailing Address - Phone:270-715-5437
Mailing Address - Fax:
Practice Address - Street 1:234 NATCHEZ TRACE AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7995
Practice Address - Country:US
Practice Address - Phone:270-715-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023178122300000X
AK1010122300000X
TN94251223P0221X
KY91561223P0221X
KY9101223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100232870Medicaid