Provider Demographics
NPI:1134353576
Name:GRACE, AMANDA ELIZABETH (DMD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:GRACE
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 1:104 VERA CT
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-2562
Mailing Address - Country:US
Mailing Address - Phone:859-338-6779
Mailing Address - Fax:859-236-6997
Practice Address - Street 1:1080 BEN ALI DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2547
Practice Address - Country:US
Practice Address - Phone:859-236-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY87781223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100123440Medicaid