Provider Demographics
NPI:1205650116
Name:DAVIS, AMANDA MARIE (RDH)
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:MARIE
Last Name:DAVIS
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:USS BLUE RIDGE LCC 19
Mailing Address - Street 2:UNIT 100102 BOX MEDICAL
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96628
Mailing Address - Country:US
Mailing Address - Phone:231-660-2643
Mailing Address - Fax:
Practice Address - Street 1:USS BLUE RIDGE LCC 19
Practice Address - Street 2:UNIT 100102
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96628-3300
Practice Address - Country:US
Practice Address - Phone:231-660-2643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH33266124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist