Provider Demographics
NPI:1164781829
Name:AMBROSON, CLINTON THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:THOMAS
Last Name:AMBROSON
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 1:302 W NISHNA ST
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-1000
Mailing Address - Country:US
Mailing Address - Phone:319-321-4082
Mailing Address - Fax:
Practice Address - Street 1:104 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-1611
Practice Address - Country:US
Practice Address - Phone:712-542-5196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist