Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 5767 | NE |
NPI | 1003850116 |
---|---|
Provider Name | Timothy L. Ambrose |
First Address | Gallup, NM 87305-1337 |
Second Address | Gallup, NM 87301-1337 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2006 |
Last Update Date | 16/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000R7575 | (05) | NM |
416455 | (05) | AZ |