Provider Demographics
NPI:1992689756
Name:AMBROSE, AISHA ALAINE (DMD)
Entity type:Individual
Prefix:
First Name:AISHA
Middle Name:ALAINE
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4260 CHATUGE DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-1867
Mailing Address - Country:US
Mailing Address - Phone:678-772-1323
Mailing Address - Fax:
Practice Address - Street 1:15 COLLINS INDUSTRIAL WAY STE A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-6029
Practice Address - Country:US
Practice Address - Phone:770-962-3191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1239141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice