Provider Demographics
NPI:1740314293
Name:ASHLEY, CHARLES MARQUISS (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MARQUISS
Last Name:ASHLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7505 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4341
Mailing Address - Country:US
Mailing Address - Phone:262-694-7522
Mailing Address - Fax:262-697-9501
Practice Address - Street 1:7505 38TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4341
Practice Address - Country:US
Practice Address - Phone:262-694-7522
Practice Address - Fax:262-697-9501
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000741-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33638000Medicaid