Provider Demographics
NPI:1649365099
Name:CERQUEIRA, AMANDA DIXON (DDS, PA)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:DIXON
Last Name:CERQUEIRA
Suffix:
Gender:F
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 N. LAKE BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:CAROLINA BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28428
Mailing Address - Country:US
Mailing Address - Phone:910-458-3232
Mailing Address - Fax:910-458-3241
Practice Address - Street 1:1328 N. LAKE BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:CAROLINA BEACH
Practice Address - State:NC
Practice Address - Zip Code:28428
Practice Address - Country:US
Practice Address - Phone:910-458-3232
Practice Address - Fax:910-458-3241
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC75971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902229Medicaid