Provider Demographics
NPI:1356460224
Name:AMOS, EDITA (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDITA
Middle Name:
Last Name:AMOS
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 1:19531 CAMINO RDG
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3111
Mailing Address - Country:US
Mailing Address - Phone:937-208-6191
Mailing Address - Fax:
Practice Address - Street 1:2500 FUNSTON RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78234-7667
Practice Address - Country:US
Practice Address - Phone:210-762-5120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2495122300000X
TX232111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist