Provider Demographics
NPI:1326161381
Name:STODOLA, AMY JO (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:JO
Last Name:STODOLA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:JO
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1630 32ND ST NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-4048
Mailing Address - Country:US
Mailing Address - Phone:319-362-8657
Mailing Address - Fax:
Practice Address - Street 1:1630 32ND ST NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-4048
Practice Address - Country:US
Practice Address - Phone:319-362-8657
Practice Address - Fax:319-362-1824
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA 080651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2220020Medicaid
IAIA 08065OtherLICENSE
IA36871OtherBC & BS PROVIDER #