Provider Demographics
NPI:1548948862
Name:DIVITTORIO, AMANDA LYNN (DDS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:DIVITTORIO
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 1:2511 WILLOWICK RD APT 508
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-3976
Mailing Address - Country:US
Mailing Address - Phone:504-376-7979
Mailing Address - Fax:
Practice Address - Street 1:4665 SWEETWATER BLVD
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-3135
Practice Address - Country:US
Practice Address - Phone:281-265-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist