Provider Demographics
NPI:1235158452
Name:JORGENSEN, AMANDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:JORGENSEN
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 1:1410 SE ROSEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-8350
Mailing Address - Country:US
Mailing Address - Phone:515-778-4278
Mailing Address - Fax:
Practice Address - Street 1:100 SW BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111
Practice Address - Country:US
Practice Address - Phone:515-986-3926
Practice Address - Fax:515-986-5116
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08223122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0293605Medicaid