Provider Demographics
NPI:1063738920
Name:GRAU, AMANDA BAKER (DMD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:BAKER
Last Name:GRAU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:NICOLE
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:10715 TIERRASANTA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124
Mailing Address - Country:US
Mailing Address - Phone:858-278-6444
Mailing Address - Fax:
Practice Address - Street 1:10715 TIERRASANTA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124
Practice Address - Country:US
Practice Address - Phone:513-777-7883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8998122300000X
OH30023394122300000X
CA61277122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist