Healthcare Provider Details

I. General information

NPI: 1972159010
Provider Name (Legal Business Name): AMALIE VANCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 WILLIAMS DR STE 111
GEORGETOWN TX
78628-3268
US

IV. Provider business mailing address

205 E UNIVERSITY AVE STE 200
GEORGETOWN TX
78626-6821
US

V. Phone/Fax

Practice location:
  • Phone: 877-800-5722
  • Fax:
Mailing address:
  • Phone: 512-994-1933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number34290
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number34290
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: