Provider Demographics
NPI:1922790369
Name:MARTIN, AMANDA DANIELLE (DDS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DANIELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2196 REIMER RD
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-8441
Mailing Address - Country:US
Mailing Address - Phone:330-388-7707
Mailing Address - Fax:
Practice Address - Street 1:4184 PEARL RD STE 103
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-6641
Practice Address - Country:US
Practice Address - Phone:330-236-0677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0271231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice