Provider Demographics
NPI:1386389690
Name:STATER, AMANDA PAIGE (DDS)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:PAIGE
Last Name:STATER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:PAIGE
Other - Last Name:CRUMMETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8344 BENT OAK DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-6369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1015 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6706
Practice Address - Country:US
Practice Address - Phone:843-486-3144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC10401122300000X
IN12013783A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program