Provider Demographics
NPI:1821677642
Name:DISNEY, AMANDA KATE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KATE
Last Name:DISNEY
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 1:909 FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3018
Mailing Address - Country:US
Mailing Address - Phone:201-873-1817
Mailing Address - Fax:
Practice Address - Street 1:1885 ROUTE 57 UNIT 1
Practice Address - Street 2:
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-3477
Practice Address - Country:US
Practice Address - Phone:908-441-7038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI028714001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program