Provider Demographics
NPI:1063864601
Name:MAIZE, AMANDA LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LEE
Last Name:MAIZE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5511 E 82ND ST STE F
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-4515
Mailing Address - Country:US
Mailing Address - Phone:317-842-1903
Mailing Address - Fax:
Practice Address - Street 1:5511 E 82ND ST STE F
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-4515
Practice Address - Country:US
Practice Address - Phone:317-842-1903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012630A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice