Provider Demographics
NPI:1649305814
Name:MARTIN, AMBROSE MILLER III (DDS)
Entity type:Individual
Prefix:DR
First Name:AMBROSE
Middle Name:MILLER
Last Name:MARTIN
Suffix:III
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 1:2610 ESPLANADE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-3321
Mailing Address - Country:US
Mailing Address - Phone:504-482-9919
Mailing Address - Fax:504-482-9921
Practice Address - Street 1:2610 ESPLANADE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-3321
Practice Address - Country:US
Practice Address - Phone:504-482-9919
Practice Address - Fax:504-482-9921
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA46711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA970847OtherUNITED CONCORDIA
LA1846716Medicaid