Provider Demographics
NPI:1417527375
Name:AMAYA, RICARDO JOSE
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:JOSE
Last Name:AMAYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 LINCOLN ST 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-4603
Mailing Address - Country:US
Mailing Address - Phone:915-497-7192
Mailing Address - Fax:
Practice Address - Street 1:9900 LINCOLN ST 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-4603
Practice Address - Country:US
Practice Address - Phone:915-497-7192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033238122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist