Provider Demographics
NPI:1649727108
Name:MCKEEFRY, AMANDA MARIE (RDH)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:MCKEEFRY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:THEYEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:3894 TALL PINE CT
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-8756
Mailing Address - Country:US
Mailing Address - Phone:920-619-8865
Mailing Address - Fax:
Practice Address - Street 1:2304 LINEVILLE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313
Practice Address - Country:US
Practice Address - Phone:920-434-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10960-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist