Healthcare Provider Details

I. General information

NPI: 1821176009
Provider Name (Legal Business Name): AMANDA MARIE DUTRA RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 CHORRO ST
SAN LUIS OBISPO CA
93401
US

IV. Provider business mailing address

753 CORBETT CYN RD
ARROYO GRANDE CA
93420
US

V. Phone/Fax

Practice location:
  • Phone: 805-543-6535
  • Fax:
Mailing address:
  • Phone: 805-710-4272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number57717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: