MEDICARE: MS. AMANDA BERNARTZ RDH

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	124Q00000X	Dental Hygienist	007372	CT

General Provider Information

NPI Number	:	1811333412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMANDA BERNARTZ RDH

Provider Business Mailing Address
First Line	:	763 BURNSIDE AVE
Second Line	:
City	:	EAST HARTFORD
State	:	CT
Zip	:	06108-2791
Country	:	US
Telephone Number	:	860-291-9154
Fax Number	:	860-291-9728

Provider Business Practice Location Address
First Line	:	15 MERCER AVE
Second Line	:
City	:	EAST HARTFORD
State	:	CT
Zip	:	06118-1517
Country	:	US
Telephone Number	:	860-622-5514
Fax Number	:	860-622-5513

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

Provider Enumeration Date	:	05/22/2013
Last Update Date	:	05/22/2013

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