=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679871511
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA DELOATCHE KLAYUM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2011
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1260 BROADCASTING RD
-----------------------------------------------------
City | WYOMISSING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19610-3223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-376-3210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 SHREWSBURY CT
-----------------------------------------------------
City | READING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19608-8509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-486-9891
-----------------------------------------------------
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 | DS038740
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------