MEDICARE: DR. AMANDA MITCHELL GROSS DDS, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	34250	TX
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DD5581	NM
3	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	34250	TX

General Provider Information

NPI Number	:	1164989349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMANDA MITCHELL GROSS DDS, MS

Provider Business Mailing Address
First Line	:	1407 FRANKLIN DELL
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-7481
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5665 WOODROW BEAN
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79924-4100
Country	:	US
Telephone Number	:	915-751-7779
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2019
Last Update Date	:	09/07/2022

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