Provider Demographics
NPI:1285029157
Name:EHLERT KRAGOR, AMBRE A (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:AMBRE
Middle Name:A
Last Name:EHLERT KRAGOR
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:AMBRE
Other - Middle Name:A
Other - Last Name:EHLERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:217 WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-7777
Mailing Address - Country:US
Mailing Address - Phone:206-854-8585
Mailing Address - Fax:770-213-8954
Practice Address - Street 1:217 WHITE OAK DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-7777
Practice Address - Country:US
Practice Address - Phone:206-854-8585
Practice Address - Fax:770-213-8954
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0149351223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN014935OtherGEORGIA DENTAL LICENSE