Provider Demographics
NPI:1447366307
Name:AMBROSE, JERROLD ROBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:ROBERT
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1584 SAYBROOK ROAD
Mailing Address - Street 2:
Mailing Address - City:HADDAM
Mailing Address - State:CT
Mailing Address - Zip Code:06438
Mailing Address - Country:US
Mailing Address - Phone:860-345-2404
Mailing Address - Fax:
Practice Address - Street 1:1584 SAYBROOK RD
Practice Address - Street 2:
Practice Address - City:HADDAM
Practice Address - State:CT
Practice Address - Zip Code:06438
Practice Address - Country:US
Practice Address - Phone:860-345-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4522122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist