Provider Demographics
NPI:1457747123
Name:AMBARAM, ROHIN
Entity Type:Individual
Prefix:
First Name:ROHIN
Middle Name:
Last Name:AMBARAM
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 1:18 AUTUMN LEAF DR
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-2607
Mailing Address - Country:US
Mailing Address - Phone:916-517-3481
Mailing Address - Fax:
Practice Address - Street 1:19100 VENTURA BLVD STE 3
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3234
Practice Address - Country:US
Practice Address - Phone:916-517-3481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
CA1000211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program