Provider Demographics
NPI:1316111081
Name:DELWICHE, AMANDA LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LYNN
Last Name:DELWICHE
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 1:2801 YULUPA AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-9115
Mailing Address - Country:US
Mailing Address - Phone:707-526-6165
Mailing Address - Fax:707-526-6238
Practice Address - Street 1:2801 YULUPA AVE
Practice Address - Street 2:SUITE D
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-9115
Practice Address - Country:US
Practice Address - Phone:707-526-6165
Practice Address - Fax:707-526-6238
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA519151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice