Provider Demographics
NPI:1639263825
Name:DONNELLY, AMANDA R (DMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:R
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:PENINSULA
Mailing Address - State:OH
Mailing Address - Zip Code:44264-9792
Mailing Address - Country:US
Mailing Address - Phone:330-928-0616
Mailing Address - Fax:
Practice Address - Street 1:742 GRAHAM RD
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-1055
Practice Address - Country:US
Practice Address - Phone:330-929-2616
Practice Address - Fax:330-929-2636
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH213421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH01496920OtherUNITED CONCORDIA PROVIDER