Provider Demographics
NPI:1821661463
Name:MANN, AMANDA (DMD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MANN
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 1:857 KEUSCH LN
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-2987
Mailing Address - Country:US
Mailing Address - Phone:859-358-0711
Mailing Address - Fax:
Practice Address - Street 1:517 E 5TH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGBURG
Practice Address - State:IN
Practice Address - Zip Code:47542-1004
Practice Address - Country:US
Practice Address - Phone:859-358-0711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013674A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist