Provider Demographics
NPI:1043831860
Name:MORGENTHAL, AMANDA LAUREN (DDS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LAUREN
Last Name:MORGENTHAL
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 1:1245 SE 3RD ST STE A1
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2162
Mailing Address - Country:US
Mailing Address - Phone:541-318-5688
Mailing Address - Fax:
Practice Address - Street 1:2475 BROADWAY BLUFFS DR STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8147
Practice Address - Country:US
Practice Address - Phone:573-777-9282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD116261223P0221X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program