Provider Demographics
NPI:1710327556
Name:BOUSTANY, AMANDA SARA (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:SARA
Last Name:BOUSTANY
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 CAPITOL ST
Mailing Address - Street 2:SUITE 914
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1749
Mailing Address - Country:US
Mailing Address - Phone:304-345-1248
Mailing Address - Fax:304-345-1249
Practice Address - Street 1:405 CAPITOL ST
Practice Address - Street 2:SUITE 914
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1749
Practice Address - Country:US
Practice Address - Phone:304-345-1248
Practice Address - Fax:304-345-1249
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV41801223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics