Basic Information
| Provider Information | |||||||||
| NPI: | 1720356520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAVINGS | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PDHA 1 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLIAMS | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PDHA 1 | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 86 | ||||||||
| Address2: | |||||||||
| City: | MEKORYUK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996300086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078272078 | ||||||||
| FaxNumber: | 9078278351 | ||||||||
| Practice Location | |||||||||
| Address1: | 829 CHIEF EDDIE HOFFMAN HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078278111 | ||||||||
| FaxNumber: | 9078278351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2011 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | 11-082-PDHA1 | AK | Y | Dental Providers | Dentist | Dental Public Health |
ID Information
| ID | Type | State | Issuer | Description | 11-082-PDHA1 | 01 | AK | PDHA 1 CERTIFICATION NUMBER | OTHER |