Provider Demographics
NPI:1821764747
Name:COLLINS, AMANDA MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20933
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87154-0933
Mailing Address - Country:US
Mailing Address - Phone:505-321-4268
Mailing Address - Fax:
Practice Address - Street 1:1500 IDALIA STE B
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-6303
Practice Address - Country:US
Practice Address - Phone:505-867-2291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH5344124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist