Provider Demographics
NPI:1750716460
Name:HOGAN, AMANDA G (RDA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:G
Last Name:HOGAN
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-3036
Mailing Address - Country:US
Mailing Address - Phone:253-227-3571
Mailing Address - Fax:
Practice Address - Street 1:646 S STATE ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3036
Practice Address - Country:US
Practice Address - Phone:253-227-3571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60180023126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant