Provider Demographics
NPI:1922284470
Name:AMANDA CERQUEIRA, DDS, PA
Entity Type:Organization
Organization Name:AMANDA CERQUEIRA, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:CERQUEIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-458-3232
Mailing Address - Street 1:1328 N LAKE PARK BLVD
Mailing Address - Street 2:STE. 107
Mailing Address - City:CAROLINA BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28428-3935
Mailing Address - Country:US
Mailing Address - Phone:910-458-3232
Mailing Address - Fax:910-458-3253
Practice Address - Street 1:1328 N LAKE PARK BLVD
Practice Address - Street 2:STE. 107
Practice Address - City:CAROLINA BEACH
Practice Address - State:NC
Practice Address - Zip Code:28428-3935
Practice Address - Country:US
Practice Address - Phone:910-458-3232
Practice Address - Fax:910-458-3253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC75971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty