Healthcare Provider Details

I. General information

NPI: 1003650862
Provider Name (Legal Business Name): AMANDA CLAIRE MOBERLY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LEGACY DR
BEREA KY
40403-9594
US

IV. Provider business mailing address

401 HIGHLAND PARK DR
RICHMOND KY
40475-3839
US

V. Phone/Fax

Practice location:
  • Phone: 859-986-2323
  • Fax:
Mailing address:
  • Phone: 859-626-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD-00144
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: