Provider Demographics
NPI:1649979089
Name:CRAIG, AMANDA JEAN
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:CRAIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10252 W ADAMS AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-5849
Mailing Address - Country:US
Mailing Address - Phone:210-567-3672
Mailing Address - Fax:
Practice Address - Street 1:10252 W ADAMS AVE STE 101
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-5849
Practice Address - Country:US
Practice Address - Phone:254-206-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX399801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program