Provider Demographics
NPI:1255173597
Name:ENGELBART, AMANDA ROSE (DDS)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:ROSE
Last Name:ENGELBART
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 1:205 RIVER PLACE DR UNIT 315
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-0056
Mailing Address - Country:US
Mailing Address - Phone:402-853-2302
Mailing Address - Fax:
Practice Address - Street 1:540 W HILL ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-2117
Practice Address - Country:US
Practice Address - Phone:706-595-5152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-08
Last Update Date:2024-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1234021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice