=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043538846
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA M HILLIS D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2010
-----------------------------------------------------
Last Update Date | 10/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7421 MEXICO RD
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-1369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-970-7902
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1173 REELFOOT LAKE DR
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63017-2934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-226-6840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2010012887
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------