Provider Demographics
NPI:1922302165
Name:DALEY, AMANDA M (DMD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:DALEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 TOWN ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2315
Mailing Address - Country:US
Mailing Address - Phone:860-892-7042
Mailing Address - Fax:860-823-3060
Practice Address - Street 1:47 TOWN ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2315
Practice Address - Country:US
Practice Address - Phone:860-892-7042
Practice Address - Fax:860-823-3060
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855547122300000X
CT0104191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008031899Medicaid