=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528766060
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA CARLOS DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2023
-----------------------------------------------------
Last Update Date | 02/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 WASHINGTON ST
-----------------------------------------------------
City | GLOUCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01930-4836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-282-8899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19 WASHINGTON ST APT 9
-----------------------------------------------------
City | HAVERHILL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01832-5704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | DN10000284
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------