Healthcare Provider Details

I. General information

NPI: 1306605993
Provider Name (Legal Business Name): AMANDA BEAMON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 WOLCOTT ST
WATERBURY CT
06705-1318
US

IV. Provider business mailing address

1141 WOLCOTT ST
WATERBURY CT
06705-1318
US

V. Phone/Fax

Practice location:
  • Phone: 475-559-7908
  • Fax:
Mailing address:
  • Phone: 475-559-7908
  • Fax: 475-559-7941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number14710
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: