Provider Demographics
NPI:1598832560
Name:AMBROSE, DEAN ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:DEAN
Middle Name:ALAN
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT BORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08742-4011
Mailing Address - Country:US
Mailing Address - Phone:856-430-7133
Mailing Address - Fax:732-899-0296
Practice Address - Street 1:1204 MADISON AVE
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT BORO
Practice Address - State:NJ
Practice Address - Zip Code:08742-4011
Practice Address - Country:US
Practice Address - Phone:856-430-7133
Practice Address - Fax:732-899-0296
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB48347207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC54282Medicare UPIN