Provider Demographics
NPI:1336233469
Name:GREGORY, AMANDA ANDERSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:ANDERSON
Last Name:GREGORY
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 1:1223 BOONEHILL RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-2403
Mailing Address - Country:US
Mailing Address - Phone:843-871-9924
Mailing Address - Fax:
Practice Address - Street 1:1223 BOONEHILL RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-2403
Practice Address - Country:US
Practice Address - Phone:843-871-9924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC935258Medicaid