Provider Demographics
NPI:1417517020
Name:ABTAHI, AMITICE
Entity Type:Individual
Prefix:
First Name:AMITICE
Middle Name:
Last Name:ABTAHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1166 STATE ROUTE 3 S STE 211
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1776
Mailing Address - Country:US
Mailing Address - Phone:410-721-2409
Mailing Address - Fax:
Practice Address - Street 1:1166 STATE ROUTE 3 S STE 211
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1776
Practice Address - Country:US
Practice Address - Phone:410-721-2409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16927122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist