Provider Demographics
NPI:1629239637
Name:VESTERSO, AMANDA LOUISE BONN
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LOUISE BONN
Last Name:VESTERSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LOUISE
Other - Last Name:BONN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:D D S
Mailing Address - Street 1:2810 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4010
Mailing Address - Country:US
Mailing Address - Phone:701-775-0641
Mailing Address - Fax:701-746-9328
Practice Address - Street 1:2810 17TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4010
Practice Address - Country:US
Practice Address - Phone:701-775-0641
Practice Address - Fax:701-746-9328
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice