Provider Demographics
NPI:1114433091
Name:JORDAN, AMANDA ROSE (RDH)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 HEBRON RD
Mailing Address - Street 2:
Mailing Address - City:BUCKFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04220-4136
Mailing Address - Country:US
Mailing Address - Phone:207-740-4170
Mailing Address - Fax:
Practice Address - Street 1:19 PETTINGILL ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5903
Practice Address - Country:US
Practice Address - Phone:207-513-1111
Practice Address - Fax:207-513-1197
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERDH4147124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist