Basic Information
| Provider Information | |||||||||
| NPI: | 1295046795 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANLOVE | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | D.M.D., M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W PARK ST | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 2173834752 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 W PARK ST | ||||||||
| Address2: | ORAL AND MAXILLOFACIAL SURGERY | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173833280 | ||||||||
| FaxNumber: | 2173837071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2010 | ||||||||
| LastUpdateDate: | 08/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X | ME122828 | FL | N | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | 204E00000X | 021002737 | IL | Y | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 014932200 | 05 | FL | MEDICAID | 003163495A | 05 | GA | MEDICAID |