Provider Demographics
NPI:1861691305
Name:TABOLT, ASHLEE MOREWOOD
Entity type:Individual
Prefix:
First Name:ASHLEE
Middle Name:MOREWOOD
Last Name:TABOLT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEE
Other - Middle Name:L
Other - Last Name:MOREWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3111
Mailing Address - Country:US
Mailing Address - Phone:719-562-4461
Mailing Address - Fax:
Practice Address - Street 1:2400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6067
Practice Address - Country:US
Practice Address - Phone:970-395-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-14
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-94801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice