MEDICARE: NO NAME GIVEN FATHIMA AMBRIN DDS

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	DN015341	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DN015341	OTHER	GA	NON-MEDICARE

General Provider Information

NPI Number	:	1447791231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NO NAME GIVEN FATHIMA AMBRIN DDS

Provider Business Mailing Address
First Line	:	2995 ATLANTA RD SE
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-3654
Country	:	US
Telephone Number	:	678-203-3463
Fax Number	:

Provider Business Practice Location Address
First Line	:	2995 ATLANTA RD SE
Second Line	:	STE 200
City	:	SMYRNA
State	:	GA
Zip	:	30080-3654
Country	:	US
Telephone Number	:	678-203-3463
Fax Number	:

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

Provider Enumeration Date	:	03/14/2017
Last Update Date	:	03/14/2017

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