Provider Demographics
NPI:1982969770
Name:HENRY, AMANDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 E CONGRESS PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6235
Mailing Address - Country:US
Mailing Address - Phone:815-459-4847
Mailing Address - Fax:
Practice Address - Street 1:260 E CONGRESS PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6235
Practice Address - Country:US
Practice Address - Phone:815-459-4847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029061122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist