Provider Demographics
NPI:1285126003
Name:GRODE, AMBER NICOLE (DDS)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:NICOLE
Last Name:GRODE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3828 CASS ST APT 6
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-1851
Mailing Address - Country:US
Mailing Address - Phone:605-366-2274
Mailing Address - Fax:
Practice Address - Street 1:1509 AVENUE G
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-2516
Practice Address - Country:US
Practice Address - Phone:712-325-1544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-095571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty