Provider Demographics
NPI:1437761871
Name:AINE, AMANDA (DDS)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:AINE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:GHAFFARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2305 MENDOCINO AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3157
Mailing Address - Country:US
Mailing Address - Phone:707-525-1500
Mailing Address - Fax:
Practice Address - Street 1:2305 MENDOCINO AVE STE A
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3157
Practice Address - Country:US
Practice Address - Phone:707-525-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN25189122300000X
CA1109641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist