=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154814028
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA ZELNICK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2018
-----------------------------------------------------
Last Update Date | 06/24/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 RANDOLPH RD
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73503-4535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-588-2249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 RANDOLPH RD
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73503-4535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-588-2249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019.031680
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------