Provider Demographics
NPI:1366085847
Name:TADEHARA, ASHLEY ANN
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ANN
Last Name:TADEHARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:ANN
Other - Last Name:KORRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:203 N WASHINGTON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0254
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:
Practice Address - Street 1:803 S MAIN ST STE 120
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2695
Practice Address - Country:US
Practice Address - Phone:208-848-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH61011478124Q00000X
IDDH-3580124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist