Provider Demographics
NPI:1235673740
Name:AMBASSADOR PRACTICE MANAGEMENT, LLC
Entity Type:Organization
Organization Name:AMBASSADOR PRACTICE MANAGEMENT, LLC
Other - Org Name:SC COSMETIC & IMPLANT DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NACHUM
Authorized Official - Middle Name:
Authorized Official - Last Name:AUGENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:864-647-9000
Mailing Address - Street 1:123 GROVE AVE
Mailing Address - Street 2:#101
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-2322
Mailing Address - Country:US
Mailing Address - Phone:425-503-1607
Mailing Address - Fax:425-671-0756
Practice Address - Street 1:104 W OAK HWY
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:SC
Practice Address - Zip Code:29693-2226
Practice Address - Country:US
Practice Address - Phone:864-647-9000
Practice Address - Fax:425-671-0756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3059261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental