Healthcare Provider Details

I. General information

NPI: 1255141123
Provider Name (Legal Business Name): AMANDA BOWROSEN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 01/13/2025
Certification Date: 01/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 N HALSTED ST
CHICAGO IL
60657-1832
US

IV. Provider business mailing address

3750 N WILTON AVE APT 4
CHICAGO IL
60613-0326
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020017887
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: