Provider Demographics
NPI:1093728339
Name:AMBAT, PURITA EPISCOPE (DMD)
Entity Type:Individual
Prefix:DR
First Name:PURITA
Middle Name:EPISCOPE
Last Name:AMBAT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 GRAND STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211
Mailing Address - Country:US
Mailing Address - Phone:718-388-7007
Mailing Address - Fax:718-388-7007
Practice Address - Street 1:749 GRAND STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211
Practice Address - Country:US
Practice Address - Phone:718-388-7007
Practice Address - Fax:718-388-7007
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036611208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00715417Medicaid