MEDICARE: DR. JERROLD ROBERT AMBROSE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	4522	CT

General Provider Information

NPI Number	:	1447366307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERROLD ROBERT AMBROSE DMD

Provider Business Mailing Address
First Line	:	1584 SAYBROOK ROAD
Second Line	:
City	:	HADDAM
State	:	CT
Zip	:	06438
Country	:	US
Telephone Number	:	860-345-2404
Fax Number	:

Provider Business Practice Location Address
First Line	:	1584 SAYBROOK RD
Second Line	:
City	:	HADDAM
State	:	CT
Zip	:	06438
Country	:	US
Telephone Number	:	860-345-2404
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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