Healthcare Provider Details

I. General information

NPI: 1164781829
Provider Name (Legal Business Name): CLINTON THOMAS AMBROSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E WASHINGTON ST
CLARINDA IA
51632-1611
US

IV. Provider business mailing address

302 W NISHNA ST
CLARINDA IA
51632-1000
US

V. Phone/Fax

Practice location:
  • Phone: 712-542-5196
  • Fax:
Mailing address:
  • Phone: 319-321-4082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number08908
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: