Provider Demographics
NPI:1215424353
Name:WILSON, ASHLEY ELIZABETH (DENTAL HYGIENIST)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ELIZABETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:ELIZABETH
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7558 FOREST VALLEY LOOP
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80908-5647
Mailing Address - Country:US
Mailing Address - Phone:757-351-9180
Mailing Address - Fax:
Practice Address - Street 1:1079 SPACE CENTER DR UNIT 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-3612
Practice Address - Country:US
Practice Address - Phone:719-596-3481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-14
Last Update Date:2018-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.002024806124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODH.002024806OtherDORA - DENTAL HYGIENE LICENSE.