Provider Demographics
NPI:1568542868
Name:WISEMAN, AMANDA KAY (DA)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:KAY
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7392 PULLMAN CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3910
Mailing Address - Country:US
Mailing Address - Phone:317-698-9791
Mailing Address - Fax:
Practice Address - Street 1:9443 E 38TH ST
Practice Address - Street 2:DENTAL CLINIC
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46235-2132
Practice Address - Country:US
Practice Address - Phone:317-890-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant