MEDICARE: AMANDA YING GU DMD

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	DS044519	PA

General Provider Information

NPI Number	:	1710732441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA YING GU DMD

Provider Business Mailing Address
First Line	:	3 MENLO TER
Second Line	:
City	:	EDISON
State	:	NJ
Zip	:	08820-3505
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7258 CASTOR AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1109
Country	:	US
Telephone Number	:	215-728-1144
Fax Number	:

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

Provider Enumeration Date	:	04/17/2024
Last Update Date	:	04/17/2024

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