MEDICARE: DR. AMENDA ST. HILAIRE DDS, MPH

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	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	36368	TX

General Provider Information

NPI Number	:	1285251975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMENDA ST. HILAIRE DDS, MPH

Provider Business Mailing Address
First Line	:	25590 PROSPECT AVE APT 11A
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-3145
Country	:	US
Telephone Number	:	954-914-3538
Fax Number	:

Provider Business Practice Location Address
First Line	:	2817 W LOOP 250 N STE B
Second Line	:
City	:	MIDLAND
State	:	TX
Zip	:	79705-3205
Country	:	US
Telephone Number	:	432-694-4800
Fax Number	:

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

Provider Enumeration Date	:	06/29/2020
Last Update Date	:	08/05/2020

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