Provider Demographics
NPI:1578306411
Name:WIRTJES, AMANDA NICOLE (RDH)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:NICOLE
Last Name:WIRTJES
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:NICOLE
Other - Last Name:RUESGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6238 ARDENNES STREET
Mailing Address - Street 2:
Mailing Address - City:FORT LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-432-8170
Mailing Address - Fax:910-432-3023
Practice Address - Street 1:6238 ARDENNES STREET
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-432-8170
Practice Address - Fax:910-423-3023
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12014124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty