Provider Demographics
NPI:1700972395
Name:AMBROSE, JOHN HUTCHINGS JR (DMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:HUTCHINGS
Last Name:AMBROSE
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 PIERCE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2871
Mailing Address - Country:US
Mailing Address - Phone:478-743-0901
Mailing Address - Fax:478-745-8615
Practice Address - Street 1:4536 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:SUITE 211
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6200
Practice Address - Country:US
Practice Address - Phone:770-455-1238
Practice Address - Fax:770-452-6421
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0127371223G0001X, 1223P0221X
VA04014112481223G0001X
IN12010811A1223G0001X
NY50-052728-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9170714Medicaid
GA29364594AMedicaid
IN200519740AMedicaid