Provider Demographics
NPI:1073052825
Name:MIRANDA, LORENZO (DDS)
Entity Type:Individual
Prefix:DR
First Name:LORENZO
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:LORENZO
Other - Middle Name:
Other - Last Name:MIRANDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:135 MUIR RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3616
Mailing Address - Country:US
Mailing Address - Phone:407-694-6684
Mailing Address - Fax:
Practice Address - Street 1:4800 LAKEWOOD RANCH BLVD
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34211-4953
Practice Address - Country:US
Practice Address - Phone:941-405-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN232491223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program