Provider Demographics
NPI:1326228883
Name:ROPER, AMANDA SUZANNE (DDS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUZANNE
Last Name:ROPER
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 1:555 W CANFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7892
Mailing Address - Country:US
Mailing Address - Phone:208-762-8750
Mailing Address - Fax:
Practice Address - Street 1:555 W CANFIELD AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-7892
Practice Address - Country:US
Practice Address - Phone:208-762-8750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-40861223G0001X
WADE000111511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice