MEDICARE: DR. AMANDA LACERDA 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	1223G0001X	General Practice Dentistry	DDS107558	CA
2	122300000X	Dentist	DDS107558	CA

General Provider Information

NPI Number	:	1841996675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMANDA LACERDA DMD

Provider Business Mailing Address
First Line	:	1440 COLUMBIA ST APT 1403
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-3475
Country	:	US
Telephone Number	:	619-510-9895
Fax Number	:

Provider Business Practice Location Address
First Line	:	11230 SORRENTO VALLEY RD STE 130
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1338
Country	:	US
Telephone Number	:	858-682-2921
Fax Number	:

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

Provider Enumeration Date	:	02/02/2023
Last Update Date	:	02/02/2023

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