Healthcare Provider Details

I. General information

NPI: 1528807112
Provider Name (Legal Business Name): AMANDA DELWICHE, DDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4773 HOEN AVE
SANTA ROSA CA
95405-7862
US

IV. Provider business mailing address

4773 HOEN AVE
SANTA ROSA CA
95405-7862
US

V. Phone/Fax

Practice location:
  • Phone: 707-526-6165
  • Fax:
Mailing address:
  • Phone: 707-526-6165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. AMANDA DELWICHE
Title or Position: PRESIDENT
Credential: DDS
Phone: 415-307-0493