Basic Information
| Provider Information | |||||||||
| NPI: | 1912969148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | REIKO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TABA | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | REIKO | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DMD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7101 HOFF STREET | ||||||||
| Address2: | HQS, USA DENTAC, ATTN: CREDENTIALS OFFICE | ||||||||
| City: | FORT BENNING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065444530 | ||||||||
| FaxNumber: | 7065541933 | ||||||||
| Practice Location | |||||||||
| Address1: | 7101 HOFF STREET | ||||||||
| Address2: | HQS, USA DENTAC, ATTN: CREDENTIALS OFFICE | ||||||||
| City: | FORT BENNING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065444530 | ||||||||
| FaxNumber: | 7065541933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 07/07/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 21835 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.