Provider Demographics
NPI:1235807504
Name:JACOVANI, AMANDA (DDS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JACOVANI
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 1:464 SONORA CIR
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8510
Mailing Address - Country:US
Mailing Address - Phone:951-236-0252
Mailing Address - Fax:
Practice Address - Street 1:2878 CAMPUS PKWY STE 1
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0945
Practice Address - Country:US
Practice Address - Phone:951-571-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1069231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice