Provider Demographics
NPI:1538541693
Name:MILES, AMANDA (DHAT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:DHAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3449 E. REZANOF DRIVE
Mailing Address - Street 2:DENTAL DEPARTMENT
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-3449
Mailing Address - Country:US
Mailing Address - Phone:907-539-6717
Mailing Address - Fax:
Practice Address - Street 1:3449 E. REZANOF DRIVE
Practice Address - Street 2:DENTAL DEPARTMENT
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-3449
Practice Address - Country:US
Practice Address - Phone:907-486-9850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK247200000X125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist