Provider Demographics
NPI:1720264138
Name:MUENCHRATH, AMBROSE JOHN
Entity Type:Individual
Prefix:DR
First Name:AMBROSE
Middle Name:JOHN
Last Name:MUENCHRATH
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 1:555 W ADAMS ST
Mailing Address - Street 2:NONE
Mailing Address - City:BURNS
Mailing Address - State:OR
Mailing Address - Zip Code:97720-1408
Mailing Address - Country:US
Mailing Address - Phone:541-573-7778
Mailing Address - Fax:
Practice Address - Street 1:555 W ADAMS ST
Practice Address - Street 2:NONE
Practice Address - City:BURNS
Practice Address - State:OR
Practice Address - Zip Code:97720-1408
Practice Address - Country:US
Practice Address - Phone:541-573-7778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD-4156122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist