Provider Demographics
NPI:1841996675
Name:LACERDA, AMANDA (DMD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:LACERDA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 COLUMBIA ST APT 1403
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3475
Mailing Address - Country:US
Mailing Address - Phone:619-510-9895
Mailing Address - Fax:
Practice Address - Street 1:11230 SORRENTO VALLEY RD STE 130
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1338
Practice Address - Country:US
Practice Address - Phone:858-682-2921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1075581223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice