Provider Demographics
NPI:1518342914
Name:AMBAYE, ASFAW
Entity Type:Individual
Prefix:DR
First Name:ASFAW
Middle Name:
Last Name:AMBAYE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4145 LAWRENCEVILLE HWY NW
Mailing Address - Street 2:STE 15
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-2807
Mailing Address - Country:US
Mailing Address - Phone:678-515-0746
Mailing Address - Fax:470-355-2166
Practice Address - Street 1:3650 MARKETPLACE BLVD STE 920
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-5742
Practice Address - Country:US
Practice Address - Phone:678-515-0746
Practice Address - Fax:470-355-2166
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0150571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice