Provider Demographics
NPI:1730494147
Name:ROMSA, AMANDA (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:ROMSA
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225 MICHIGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3819
Mailing Address - Country:US
Mailing Address - Phone:262-497-4728
Mailing Address - Fax:
Practice Address - Street 1:12721 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-2178
Practice Address - Country:US
Practice Address - Phone:708-448-9415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0284611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics