Healthcare Provider Details

I. General information

NPI: 1114405859
Provider Name (Legal Business Name): AMANDA MARIE MUZZIO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2018
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

387 NE 223RD AVE
GRESHAM OR
97030-8554
US

IV. Provider business mailing address

387 NE 223RD AVE
GRESHAM OR
97030-8554
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-5450
  • Fax:
Mailing address:
  • Phone: 503-491-5450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD10884
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: