Provider Demographics
NPI:1750944344
Name:ROWE, AMANDA JODI (LD, RDA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JODI
Last Name:ROWE
Suffix:
Gender:F
Credentials:LD, RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3221
Mailing Address - Country:US
Mailing Address - Phone:480-289-0536
Mailing Address - Fax:
Practice Address - Street 1:10480 W GARVERDALE CT STE 804A
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5477
Practice Address - Country:US
Practice Address - Phone:208-376-6613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID99122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist