Provider Demographics
NPI:1194150425
Name:MAYWALT, TORI ASHLEY (DMD)
Entity type:Individual
Prefix:DR
First Name:TORI
Middle Name:ASHLEY
Last Name:MAYWALT
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:USNMRTU IWAKUNI BLDG 110 MCAS IWAKUNI
Mailing Address - Street 2:IWAKUNI, 1 MISUMI MACHI
Mailing Address - City:IWAKUNI
Mailing Address - State:YAMAGUCHI
Mailing Address - Zip Code:7400025
Mailing Address - Country:JP
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USNMRTU IWAKUNI, BLDG 110, MCAS IWAKUNI
Practice Address - Street 2:1 MISUMI MACHI
Practice Address - City:IWAKUNI
Practice Address - State:YAMAGUCHI
Practice Address - Zip Code:7400025
Practice Address - Country:JP
Practice Address - Phone:315-255-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2023-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3697-131223P0221X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry