Provider Demographics
NPI:1437176484
Name:AMBROSE, JAMES K (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:K
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:PO BOX 326
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554-0326
Mailing Address - Country:US
Mailing Address - Phone:580-782-5513
Mailing Address - Fax:580-782-5156
Practice Address - Street 1:1410 1/2 N LOUIS TITTLE AVE
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-2218
Practice Address - Country:US
Practice Address - Phone:580-782-5513
Practice Address - Fax:580-782-5156
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK43341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice