Provider Demographics
NPI:1912969148
Name:NELSON, AMANDA REIKO (DMD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:REIKO
Last Name:NELSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:REIKO
Other - Last Name:TABA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:7101 HOFF STREET
Mailing Address - Street 2:HQS, USA DENTAC, ATTN: CREDENTIALS OFFICE
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905
Mailing Address - Country:US
Mailing Address - Phone:706-544-4530
Mailing Address - Fax:706-554-1933
Practice Address - Street 1:7101 HOFF STREET
Practice Address - Street 2:HQS, USA DENTAC, ATTN: CREDENTIALS OFFICE
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:706-544-4530
Practice Address - Fax:706-554-1933
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX218351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice