Provider Demographics
NPI:1306392238
Name:WILSON, AMANDA (DDS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WILSON
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 1:2134 STATE ROUTE 208
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:NY
Mailing Address - Zip Code:12549-2613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2134 STATE ROUTE 208
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:NY
Practice Address - Zip Code:12549-2613
Practice Address - Country:US
Practice Address - Phone:845-457-5763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50058756122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist