Provider Demographics
NPI:1306811815
Name:AMBROSE, JOHN MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:AMBROSE
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 1:4445 HWY 40 E
Mailing Address - Street 2:STE 405
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558
Mailing Address - Country:US
Mailing Address - Phone:912-510-7123
Mailing Address - Fax:912-510-7126
Practice Address - Street 1:4445 HWY 40
Practice Address - Street 2:STE 405
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-4099
Practice Address - Country:US
Practice Address - Phone:912-510-7123
Practice Address - Fax:912-510-7126
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA114051223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics