Provider Demographics
NPI:1649420340
Name:WADSWORTH, AMY ROBERTSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:ROBERTSON
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2264 MCINGVALE RD
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-8710
Mailing Address - Country:US
Mailing Address - Phone:662-429-6736
Mailing Address - Fax:662-429-6752
Practice Address - Street 1:2264 MCINGVALE RD
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-8710
Practice Address - Country:US
Practice Address - Phone:662-429-6736
Practice Address - Fax:662-429-6752
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3018-971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice