Provider Demographics
NPI:1710627146
Name:VICARI, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:VICARI
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 1:2775 NE 187TH ST
Mailing Address - Street 2:PH 29
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180
Mailing Address - Country:US
Mailing Address - Phone:754-715-5303
Mailing Address - Fax:
Practice Address - Street 1:750 E 25TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013
Practice Address - Country:US
Practice Address - Phone:305-694-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-01
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRPM24051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice