Provider Demographics
NPI:1124259130
Name:MAXAM, ASHLEY (DMD)
Entity type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:
Last Name:MAXAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CALIFORNIA ST
Mailing Address - Street 2:PO BOX 577
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-1923
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:618-985-6860
Practice Address - Street 1:1501 S CARBON ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1435
Practice Address - Country:US
Practice Address - Phone:618-997-7273
Practice Address - Fax:618-997-8978
Is Sole Proprietor?:No
Enumeration Date:2009-08-07
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-028085122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019-028085OtherSTATE LICENSE NUMBER