Provider Demographics
NPI:1912557026
Name:AMANDA L. MAIZE, DMD, LLC
Entity Type:Organization
Organization Name:AMANDA L. MAIZE, DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAIZE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:262-749-4119
Mailing Address - Street 1:12904 GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5256
Mailing Address - Country:US
Mailing Address - Phone:262-749-4119
Mailing Address - Fax:
Practice Address - Street 1:12904 GRAND BLVD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5256
Practice Address - Country:US
Practice Address - Phone:262-749-4119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-19
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1063864601OtherNPI TYPE 1
IN12012630AOtherIN DENTAL LICENSE