Provider Demographics
NPI:1134374192
Name:WANTA, AMANDA J
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:WANTA
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 1:1810 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-3492
Mailing Address - Country:US
Mailing Address - Phone:715-848-4884
Mailing Address - Fax:715-845-5385
Practice Address - Street 1:401 WEST MAIL STREET
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452
Practice Address - Country:US
Practice Address - Phone:715-539-8181
Practice Address - Fax:715-539-8109
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10470016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist