Provider Demographics
NPI:1548309925
Name:JACK R. ASHLOCK, DDS PS
Entity type:Organization
Organization Name:JACK R. ASHLOCK, DDS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:R
Authorized Official - Last Name:ASHLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PS
Authorized Official - Phone:509-327-8681
Mailing Address - Street 1:12105 N RIVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-3500
Mailing Address - Country:US
Mailing Address - Phone:509-468-2068
Mailing Address - Fax:
Practice Address - Street 1:6821 N COUNTRY HOMES BLVD
Practice Address - Street 2:STE 202
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-4372
Practice Address - Country:US
Practice Address - Phone:509-327-8681
Practice Address - Fax:509-327-8562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025103DE000044701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA591231OtherUNITED CONCORDIA PROVIDER
WA5397203Medicaid