Healthcare Provider Details

I. General information

NPI: 1952197030
Provider Name (Legal Business Name): AMANDA HENRY DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 E CONGRESS PKWY STE C
CRYSTAL LAKE IL
60014-6235
US

IV. Provider business mailing address

260 E CONGRESS PKWY STE C
CRYSTAL LAKE IL
60014-6235
US

V. Phone/Fax

Practice location:
  • Phone: 815-459-4847
  • Fax:
Mailing address:
  • Phone:
  • 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 Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: AMANDA HENRY
Title or Position: OWNER
Credential:
Phone: 847-809-5312