Healthcare Provider Details

I. General information

NPI: 1235158452
Provider Name (Legal Business Name): AMANDA JORGENSEN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SW BROOKSIDE DR
GRIMES IA
50111
US

IV. Provider business mailing address

1410 SE ROSEWOOD CT
WAUKEE IA
50263-8350
US

V. Phone/Fax

Practice location:
  • Phone: 515-986-3926
  • Fax: 515-986-5116
Mailing address:
  • Phone: 515-778-4278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number08223
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: