Provider Demographics
NPI:1053748228
Name:TAYLOR, AMANDA TINESHA (DDS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:TINESHA
Last Name:TAYLOR
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 1:15046 BARNES MEADOWS CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-3188
Mailing Address - Country:US
Mailing Address - Phone:919-260-5850
Mailing Address - Fax:
Practice Address - Street 1:117 SAINT PATRICKS DR
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4574
Practice Address - Country:US
Practice Address - Phone:301-870-4553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2020-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX297901223G0001X
VA04014167581223G0001X
390200000X
MD172311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program