Healthcare Provider Details

I. General information

NPI: 1720356520
Provider Name (Legal Business Name): AMANDA SHAVINGS PDHA 1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA WILLIAMS PDHA 1

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 CHIEF EDDIE HOFFMAN HIGHWAY
BETHEL AK
99559-0528
US

IV. Provider business mailing address

PO BOX 86
MEKORYUK AK
99630-0086
US

V. Phone/Fax

Practice location:
  • Phone: 907-827-8111
  • Fax: 907-827-8351
Mailing address:
  • Phone: 907-827-2078
  • Fax: 907-827-8351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number11-082-PDHA1
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: