Provider Demographics
NPI:1033877725
Name:LOURENCO, AMANDA M (RDH, COMT)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:M
Last Name:LOURENCO
Suffix:
Gender:F
Credentials:RDH, COMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1476 W HERNDON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-4401
Mailing Address - Country:US
Mailing Address - Phone:559-978-5413
Mailing Address - Fax:
Practice Address - Street 1:1476 W HERNDON AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-4401
Practice Address - Country:US
Practice Address - Phone:559-978-5413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28715124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist