Provider Demographics
NPI:1396790077
Name:RAMBO, HENRY M (DDS)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:M
Last Name:RAMBO
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 1:21 INDUSTRIAL BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301
Mailing Address - Country:US
Mailing Address - Phone:610-644-6497
Mailing Address - Fax:610-644-6622
Practice Address - Street 1:21 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301
Practice Address - Country:US
Practice Address - Phone:610-644-6497
Practice Address - Fax:610-644-6622
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017526L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
174269Medicare ID - Type Unspecified
T29922Medicare UPIN