=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831838382
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA JO BOGGS DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2022
-----------------------------------------------------
Last Update Date | 06/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1309 GREENE ST
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45750-9172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-374-0123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 MISSION RD
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45750-9435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-668-7915
-----------------------------------------------------
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 | 30.026861
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------