Healthcare Provider Details

I. General information

NPI: 1316397599
Provider Name (Legal Business Name): DIANNE HOLLY AMBROSEK CDA,E.F.D.A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 HAMILTON ROAD
FORT SILL OK
73503
US

IV. Provider business mailing address

652 HAMILTON ROAD
FORT SILL OK
73503
US

V. Phone/Fax

Practice location:
  • Phone: 580-442-3905
  • Fax: 580-442-4002
Mailing address:
  • Phone: 580-442-3905
  • Fax: 580-442-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: