Healthcare Provider Details

I. General information

NPI: 1770052151
Provider Name (Legal Business Name): AMANDA PRENTICE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE FL 4
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

1104 W MADISON ST APT 3N
CHICAGO IL
60607-2029
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-6669
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number018002085
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: