Provider Demographics
NPI:1114572229
Name:BLANKENSHIP, AMANDA C (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:C
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 WATCHMEN LN
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:NC
Mailing Address - Zip Code:28326-1002
Mailing Address - Country:US
Mailing Address - Phone:419-764-3656
Mailing Address - Fax:
Practice Address - Street 1:SMOKE BOMB HILL DENTAL CLINIC 3817 GRUBER RD
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-396-1571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0258731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00000Medicaid