Provider Demographics
NPI:1609415595
Name:KILPATRICK, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KILPATRICK
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 1:11714 BELLE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:RILEY
Mailing Address - State:MI
Mailing Address - Zip Code:48041-4322
Mailing Address - Country:US
Mailing Address - Phone:313-260-2601
Mailing Address - Fax:
Practice Address - Street 1:11714 BELLE RIVER RD
Practice Address - Street 2:
Practice Address - City:RILEY
Practice Address - State:MI
Practice Address - Zip Code:48041-4322
Practice Address - Country:US
Practice Address - Phone:313-260-2601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-25
Last Update Date:2019-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902016450124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist